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Sexual Precocity in a 16-Month-Old- j! `+ y% _' c, h
Boy Induced by Indirect Topical
6 ~7 [4 _: f6 _! s- V% C' U: l+ GExposure to Testosterone# K& `5 t1 P; y/ O+ d& e4 Z1 n. F [" I
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 K3 K7 l( b! W! W, rand Kenneth R. Rettig, MD1- v' X0 h1 A$ g) n. a. |9 ~! W; v
Clinical Pediatrics
3 M; v- f# I- K) TVolume 46 Number 65 q ?: O5 y$ _/ l' l6 T
July 2007 540-543# Z2 ~- s; `; w8 b; r3 S
© 2007 Sage Publications- s( S: ]" s) F$ j/ f
10.1177/0009922806296651( I' a; \0 X! ?
http://clp.sagepub.com
1 D+ V+ Y: E9 B5 |" ]: t% M$ ?hosted at
# ^8 U9 v7 g5 |http://online.sagepub.com. v2 W& {8 C& q) n' n) j1 j
Precocious puberty in boys, central or peripheral,& ?7 e8 H) }8 n4 e3 I
is a significant concern for physicians. Central
" ^: h* K+ ~' ]- z4 d) A3 `7 Aprecocious puberty (CPP), which is mediated
, A# {) z" M' j' x2 cthrough the hypothalamic pituitary gonadal axis, has2 j* a, d9 @" D4 F. q
a higher incidence of organic central nervous system
/ p/ p+ K1 ?# _- S1 ]2 Tlesions in boys.1,2 Virilization in boys, as manifested d, P4 D X( i1 R
by enlargement of the penis, development of pubic P/ `9 d9 _. W# Q' U
hair, and facial acne without enlargement of testi-4 j. U% C2 Y G2 p
cles, suggests peripheral or pseudopuberty.1-3 We6 r4 v! {5 T0 g- p( p
report a 16-month-old boy who presented with the
$ O/ _6 k- h8 G1 Menlargement of the phallus and pubic hair develop-
1 [. E0 e1 ~5 x/ |1 ]( z7 x8 kment without testicular enlargement, which was due
) \# m \8 m1 H7 J9 c: R. ?4 ^3 z: Q% ^to the unintentional exposure to androgen gel used by
& ? v& {, D7 E: _, W4 uthe father. The family initially concealed this infor-
& q) D' s# ?, V9 r U+ {2 L4 x) q' Smation, resulting in an extensive work-up for this! x) n* o" }3 B. {
child. Given the widespread and easy availability of
( v. x* s% @( A9 vtestosterone gel and cream, we believe this is proba-
" o( @! e+ O5 dbly more common than the rare case report in the
4 x: k% P& c! e$ [literature.4
8 F. c9 a9 s- uPatient Report) S A' Y+ ]5 C6 F
A 16-month-old white child was referred to the: s2 n# G* ]8 Z6 A' |; K8 ^+ ?3 W* a
endocrine clinic by his pediatrician with the concern0 i% X" o3 ^5 ]' }6 c
of early sexual development. His mother noticed0 M4 g) d+ B4 J# d/ e7 C
light colored pubic hair development when he was
# d7 J8 C" G. g3 L0 e/ bFrom the 1Division of Pediatric Endocrinology, 2University of
- v0 I$ n+ x! rSouth Alabama Medical Center, Mobile, Alabama.
{3 @6 x- z9 RAddress correspondence to: Samar K. Bhowmick, MD, FACE,
4 `# l! v/ h$ S( `. yProfessor of Pediatrics, University of South Alabama, College of" a4 \, T' @; W; {
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
* ~( l4 i1 p) je-mail: [email protected].4 b0 t& W+ L1 _" r7 H
about 6 to 7 months old, which progressively became2 D' x/ {1 ]) W! l' D* c
darker. She was also concerned about the enlarge-
& K" i' P4 g! [; sment of his penis and frequent erections. The child9 I; ^' O8 x# I/ G% G: J3 z+ n
was the product of a full-term normal delivery, with4 g- t- D1 i& f2 T M" T' {2 A O
a birth weight of 7 lb 14 oz, and birth length of
" c$ U( S8 P4 i6 ]20 inches. He was breast-fed throughout the first year) x3 q+ K: Y+ y- n! A0 q9 E% Y+ Z
of life and was still receiving breast milk along with
; N0 F6 Y4 I; b: }8 Q J; V! esolid food. He had no hospitalizations or surgery,
! @2 s1 N) ?6 t' k6 j/ W; y1 iand his psychosocial and psychomotor development
9 r1 x3 @5 {6 F: ~: @was age appropriate.
; B4 h7 C- [8 o# }- {The family history was remarkable for the father,
8 B! z: R+ [) swho was diagnosed with hypothyroidism at age 16,
9 A6 C5 z$ G$ q, X- l+ G0 I0 j* _which was treated with thyroxine. The father’s
9 b, C9 \2 r' m/ z0 sheight was 6 feet, and he went through a somewhat
* Z# |3 i# m2 g' N/ `* Yearly puberty and had stopped growing by age 14.: M# }: g/ c1 K6 @: L
The father denied taking any other medication. The
6 k8 e. D$ f' e" r6 e- Y, schild’s mother was in good health. Her menarche5 ]) V$ }3 {# R7 Z
was at 11 years of age, and her height was at 5 feet. J3 a( N& U* i$ {) o* T
5 inches. There was no other family history of pre-
. C* ^4 H3 W" K% y: ]# d; Q( ncocious sexual development in the first-degree rela-
) W# i3 H7 [# }6 Y8 R6 y4 w; c N% Dtives. There were no siblings.
3 L8 d+ z8 t h, r) SPhysical Examination
( z* L& i- B- R4 f. @The physical examination revealed a very active,+ Q/ _6 W. V9 B
playful, and healthy boy. The vital signs documented
' ^9 D* }% G# k: `2 }0 {6 [4 ca blood pressure of 85/50 mm Hg, his length was |( S4 t# H f+ Y- p, ]
90 cm (>97th percentile), and his weight was 14.4 kg/ G- l' c; M, T- h- `
(also >97th percentile). The observed yearly growth& R6 f- g& c) N' \. Y
velocity was 30 cm (12 inches). The examination of
+ m+ g% {9 O5 Z3 |4 k Kthe neck revealed no thyroid enlargement.( M5 [$ Q7 s: e4 ^ K/ O1 `
The genitourinary examination was remarkable for
% X, T, u! ]- N/ ienlargement of the penis, with a stretched length of
2 o6 f4 Y8 R! g1 A# r8 T. G0 @8 cm and a width of 2 cm. The glans penis was very well
- s; b4 W: \ f9 r2 H7 H$ o2 tdeveloped. The pubic hair was Tanner II, mostly around
/ P* A4 p8 }. P0 t _3 T* M) u540
" H# t) ^( k3 t( d/ }7 P7 v" Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 {4 t, Z6 t/ W2 W
the base of the phallus and was dark and curled. The
' y2 w1 J( r* g1 r" {testicular volume was prepubertal at 2 mL each.$ B- h) L7 l f. R+ e: ]9 ^
The skin was moist and smooth and somewhat
- Y: v( M; L# z9 G& \- a$ ~oily. No axillary hair was noted. There were no
0 o+ ^. _$ v4 ~* i, x4 A4 l: r# gabnormal skin pigmentations or café-au-lait spots.- @- e: V! @$ q% g8 b6 p
Neurologic evaluation showed deep tendon reflex 2+( j/ X$ v2 j# X8 q4 I$ j S& ^
bilateral and symmetrical. There was no suggestion4 t( J9 ]- _% @' _( u
of papilledema.
3 @) V( c. W1 nLaboratory Evaluation( O# {8 d; h4 W: A6 Y
The bone age was consistent with 28 months by3 ]/ @& u% ^* g" Z
using the standard of Greulich and Pyle at a chrono-
. E. |( v3 a0 {, Jlogic age of 16 months (advanced).5 Chromosomal9 L6 h, f' P6 V4 u, i- Q
karyotype was 46XY. The thyroid function test0 N# F' s9 r/ | O' c# y( X+ {
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% b( A+ y) w: ?& H/ w" a1 ~lating hormone level was 1.3 µIU/mL (both normal).
& D2 e2 K ?* E, j3 U! r9 j7 U* kThe concentrations of serum electrolytes, blood; H2 z$ s" B8 ?* q- N
urea nitrogen, creatinine, and calcium all were8 \5 E. B, h4 N# T* S2 V4 I/ }
within normal range for his age. The concentration: x! n) e$ W6 K! e6 z1 f+ A
of serum 17-hydroxyprogesterone was 16 ng/dL
$ O7 Y5 \2 |5 a(normal, 3 to 90 ng/dL), androstenedione was 20
k8 m; j# c9 L' Y; Fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- X8 x+ \; ]& L q" ~, R
terone was 38 ng/dL (normal, 50 to 760 ng/dL),* _& {7 \2 l+ v/ U
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) P* l8 q! K2 q7 Z49ng/dL), 11-desoxycortisol (specific compound S)% m @/ C- ` h1 P
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-; }% O8 T2 ?; k$ \/ h2 q4 q2 s$ w
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total8 g4 r- _, y/ R0 f# A5 N& E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 H9 A9 ~4 S% m( dand β-human chorionic gonadotropin was less than1 o" O. C3 V9 H3 R
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 r& v9 l2 c* d9 b% k/ r' P" Istimulating hormone and leuteinizing hormone9 _* o4 s5 q: X9 O
concentrations were less than 0.05 mIU/mL0 b1 ?5 T7 j$ k# P$ x
(prepubertal).
( b, R7 b# h8 l* o, E6 oThe parents were notified about the laboratory0 N- j' S* o, D5 H ?
results and were informed that all of the tests were
) i# E# n+ i f* |6 ^; h3 Knormal except the testosterone level was high. The
' F1 S; K0 p, u" @follow-up visit was arranged within a few weeks to h2 }2 W, E% V5 ^( r' o
obtain testicular and abdominal sonograms; how-
n9 u" j7 |7 e! g! d4 uever, the family did not return for 4 months.
3 t9 c N' p, s4 o" j9 a0 e% T. rPhysical examination at this time revealed that the! e# M. Q! t$ J3 s9 L. Q W
child had grown 2.5 cm in 4 months and had gained
- R, j) Z0 N4 Q& F2 kg of weight. Physical examination remained: Q4 n& f! N5 d0 _0 v9 q
unchanged. Surprisingly, the pubic hair almost com-
, U: M2 p) _9 `5 t3 Zpletely disappeared except for a few vellous hairs at) L5 W7 k; f' q6 D$ N
the base of the phallus. Testicular volume was still 28 B- e' a, w% r5 ]; T4 ?
mL, and the size of the penis remained unchanged.
; f5 t+ g7 @7 y$ L2 O4 FThe mother also said that the boy was no longer hav-) Y& J ~2 |2 k, y! c0 y& G# }
ing frequent erections.
7 n1 M5 T' }% LBoth parents were again questioned about use of0 o9 E. O/ G' R1 d( T8 h: g, u
any ointment/creams that they may have applied to
D9 @8 r+ X3 c7 R( l- _the child’s skin. This time the father admitted the
7 W) v8 V! ?$ U8 a" S; ]1 mTopical Testosterone Exposure / Bhowmick et al 5414 z+ x3 `3 _- J
use of testosterone gel twice daily that he was apply-
7 b- Y+ p+ w9 [ @ing over his own shoulders, chest, and back area for( L3 X7 M) t4 T
a year. The father also revealed he was embarrassed
x9 n+ M1 T( O U- B% jto disclose that he was using a testosterone gel pre-
4 z/ I; g1 g& T5 E& fscribed by his family physician for decreased libido8 b! v2 J1 m& y& [
secondary to depression., Q5 x3 n# J( d
The child slept in the same bed with parents.2 v( X/ w' w# G4 c
The father would hug the baby and hold him on his
9 P1 G; G* v/ ~) ?chest for a considerable period of time, causing sig-1 I f4 P) [: D6 r
nificant bare skin contact between baby and father.
0 s/ ]5 }3 r% w( W5 \. |- e4 r/ s8 aThe father also admitted that after the phone call,
" V6 {! Y# M$ j0 ~8 hwhen he learned the testosterone level in the baby
( m# J! g3 L+ G- mwas high, he then read the product information
0 W7 E5 e: U6 [" `- _ upacket and concluded that it was most likely the rea-
' R/ o9 ], _ Q% I- b$ [! `son for the child’s virilization. At that time, they
& A! l1 y: l+ \" ^- fdecided to put the baby in a separate bed, and the
& k! D5 ]5 C3 F0 S. Vfather was not hugging him with bare skin and had
4 C" _ o8 L) b2 rbeen using protective clothing. A repeat testosterone
) s! ?* H% P/ j+ n1 ~, Ytest was ordered, but the family did not go to the
% E. ^: Z) j" n7 ilaboratory to obtain the test.& B! t" U' J& ~( a5 o& a
Discussion
7 r5 g) d2 B1 h' qPrecocious puberty in boys is defined as secondary: }9 c. Y8 c& R/ K) y9 [
sexual development before 9 years of age.1,4, l! l, _$ M- z* o: R/ H- `- {- B
Precocious puberty is termed as central (true) when6 [$ F- C: J* ]; b
it is caused by the premature activation of hypo-7 o1 L6 V# {% @. y9 k% l6 y6 Y
thalamic pituitary gonadal axis. CPP is more com-! c4 d& x3 }7 A4 o; H5 {8 G; e
mon in girls than in boys.1,3 Most boys with CPP
7 H/ ]) R7 e* |1 x3 ]9 N$ u) \- ?may have a central nervous system lesion that is
" ~4 y! J9 X" Oresponsible for the early activation of the hypothal-
; l- x6 y* b3 K/ Famic pituitary gonadal axis.1-3 Thus, greater empha-
+ E n) E9 P- b4 @2 ]- Ysis has been given to neuroradiologic imaging in
7 X8 [ Y2 g1 R' A* tboys with precocious puberty. In addition to viril-
7 m/ o9 Q) r7 Tization, the clinical hallmark of CPP is the symmet-: v# e G+ c" y5 e) j
rical testicular growth secondary to stimulation by
; e& a5 W+ s! C; fgonadotropins.1,3
& k3 c. {' H7 u5 A! oGonadotropin-independent peripheral preco-/ ]0 B, Y8 [9 s. _- f) M6 V, w
cious puberty in boys also results from inappropriate
6 @% o- A2 {& h# w) d: V, Y0 Z) x# Wandrogenic stimulation from either endogenous or
# J- j5 ^5 ^5 ?* V3 F- }exogenous sources, nonpituitary gonadotropin stim-. d1 N" V& P' }. M; j5 }+ V: l
ulation, and rare activating mutations.3 Virilizing0 V$ o6 E; N8 C: F% e; U6 |
congenital adrenal hyperplasia producing excessive
! H8 O4 \ s& t! \* Oadrenal androgens is a common cause of precocious' S% _/ y% W6 _1 h; J
puberty in boys.3,4" L6 t7 P8 G$ E) v
The most common form of congenital adrenal
4 [- J4 c1 |4 v1 p5 ]hyperplasia is the 21-hydroxylase enzyme deficiency.6 K+ ~8 i/ H8 i. [3 n' v, i
The 11-β hydroxylase deficiency may also result in/ }! r% [1 O R7 U
excessive adrenal androgen production, and rarely," Q# t3 ?% L" @, W) Y! q
an adrenal tumor may also cause adrenal androgen- W) Q6 C% w7 F# S# @9 w
excess.1,3
7 ^# c j8 o Y$ k& }. t% }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( E, R0 U0 H$ o# P542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* U. q, o0 P; l$ c) U/ f5 YA unique entity of male-limited gonadotropin-
& k9 ~: i1 [, R2 n& Cindependent precocious puberty, which is also known: @4 v4 E) B$ m- d
as testotoxicosis, may cause precocious puberty at a
# o- h2 E5 e( { W, overy young age. The physical findings in these boys) z+ f9 S& K2 C# L! z2 d+ l5 z
with this disorder are full pubertal development,: A$ t) f p% K5 r
including bilateral testicular growth, similar to boys$ a; C: e% _2 |* M! m
with CPP. The gonadotropin levels in this disorder
4 K3 ~$ E, x/ G5 o3 Z' z7 Q4 Rare suppressed to prepubertal levels and do not show' W3 H9 } F" X; C: @; v* \! V" x0 J( o
pubertal response of gonadotropin after gonadotropin-
3 x# i1 m9 x7 R+ w0 Lreleasing hormone stimulation. This is a sex-linked
) @9 u# d( r ~; s2 {1 lautosomal dominant disorder that affects only6 g$ w/ `4 l( ?8 w
males; therefore, other male members of the family) T8 R3 m/ q5 |6 I3 ]( z k( B# @
may have similar precocious puberty.3
% ~1 Z+ I" a- Z: U' ZIn our patient, physical examination was incon-
( Y3 M# @/ i. y" h1 ~9 G0 N& Ksistent with true precocious puberty since his testi-
' N- B4 c' z$ d0 ucles were prepubertal in size. However, testotoxicosis: [) ~0 e3 h( z8 O; M5 K
was in the differential diagnosis because his father+ z& K: J7 b U- {5 S; R
started puberty somewhat early, and occasionally,! f! p4 Z; T" w+ H$ i! g1 C- r& J8 c
testicular enlargement is not that evident in the& [ v9 D: e: W5 W
beginning of this process.1 In the absence of a neg-' u' c p0 }, u& I& B
ative initial history of androgen exposure, our
$ @. a2 z2 {0 n1 B( W, Rbiggest concern was virilizing adrenal hyperplasia,6 \4 U' C) H, d$ B* f9 I0 b6 G
either 21-hydroxylase deficiency or 11-β hydroxylase
6 ~0 V3 x! D& ideficiency. Those diagnoses were excluded by find-
# o7 _4 g+ P5 u4 n3 Qing the normal level of adrenal steroids.
% Q5 c( k& W; ~" J" [2 yThe diagnosis of exogenous androgens was strongly
5 O1 j1 z" v3 psuspected in a follow-up visit after 4 months because
$ V- z( ]! {! h h! z* H; `the physical examination revealed the complete disap-- T& g5 R, R! W
pearance of pubic hair, normal growth velocity, and
2 j6 Y+ x/ `8 o4 P4 l6 mdecreased erections. The father admitted using a testos-( \8 k5 i2 a) Q* |6 |
terone gel, which he concealed at first visit. He was
# P) m1 Q6 k q) o# ^& {2 Gusing it rather frequently, twice a day. The Physicians’2 f! d3 T2 Z" p3 o% B
Desk Reference, or package insert of this product, gel or
/ k/ Y0 t1 n2 i% Z& ~cream, cautions about dermal testosterone transfer to
7 Z7 [# _% t3 Cunprotected females through direct skin exposure.- c2 Y( x* U' l9 @. X1 W( Y }
Serum testosterone level was found to be 2 times the$ @9 C% K4 o# R: i
baseline value in those females who were exposed to
- g; {8 E' Z, @" W/ q: z1 o$ a' `even 15 minutes of direct skin contact with their male! c" n. G; A x' ^- T$ D) G1 v$ K
partners.6 However, when a shirt covered the applica-8 p0 @# z" X7 {- D
tion site, this testosterone transfer was prevented.) @. |1 [. ~4 o; E! C/ h
Our patient’s testosterone level was 60 ng/mL,
: I% ^' [/ ^- e/ e$ G$ H+ Twhich was clearly high. Some studies suggest that
6 q( e1 W5 j- X, mdermal conversion of testosterone to dihydrotestos-$ o7 t: q' `; Y3 Y: l! E
terone, which is a more potent metabolite, is more
}- W8 m. h! K- B: lactive in young children exposed to testosterone
6 H# G( C ~4 a" y) k* u; t; l' ]exogenously7; however, we did not measure a dihy-* J( `+ V$ c6 @( L3 h' @7 d& I; d
drotestosterone level in our patient. In addition to# ^) `. Z" W0 f0 A( w# s! |: M
virilization, exposure to exogenous testosterone in7 Y3 k% S' t8 O D4 H7 Q
children results in an increase in growth velocity and
; X; \ M& L9 K/ |2 hadvanced bone age, as seen in our patient.
0 G# H% E: b; e6 A5 BThe long-term effect of androgen exposure during5 Q) c$ ` V5 T. e& S& _* @! \, D1 F
early childhood on pubertal development and final. v; B# `9 S9 b+ N) b
adult height are not fully known and always remain
' V; c8 M0 |( _: Q# i2 J% {a concern. Children treated with short-term testos-
% Q8 ^' M) F0 c' S0 l9 dterone injection or topical androgen may exhibit some
3 ]6 T. g" N: }. tacceleration of the skeletal maturation; however, after% u: [' g1 `; C: s8 @
cessation of treatment, the rate of bone maturation
, Q- j3 a- m5 |decelerates and gradually returns to normal.8,9
# ?' G% \( X6 T5 G5 Q1 tThere are conflicting reports and controversy) P0 ?9 K+ W( | E4 C/ h
over the effect of early androgen exposure on adult
7 d8 @/ G9 J* y) P) U: fpenile length.10,11 Some reports suggest subnormal$ Y2 d, n4 X. N) @
adult penile length, apparently because of downreg-
- p- r. B8 ]( d" s+ Q1 L9 ?ulation of androgen receptor number.10,12 However,) j1 v N2 O @$ i. f V0 |; B
Sutherland et al13 did not find a correlation between
; L5 K5 r( B: L% a3 O5 uchildhood testosterone exposure and reduced adult
C; u, R$ u9 b" J7 i5 Npenile length in clinical studies.. l& @+ `0 Q) \
Nonetheless, we do not believe our patient is
G# Y& n! w' c6 R+ g: t- ]going to experience any of the untoward effects from
, K2 p; ]1 ]% m: r, V% ftestosterone exposure as mentioned earlier because3 N4 p) @- m) G3 B# i
the exposure was not for a prolonged period of time.+ ?- k( o" w: n3 k* F
Although the bone age was advanced at the time of0 c* k" r$ v- g# d, v) q
diagnosis, the child had a normal growth velocity at
3 R k& }" l& g7 ^* b& i7 e; [the follow-up visit. It is hoped that his final adult
% J0 W* f$ z, u3 w, |height will not be affected.
0 O: M k/ C: P7 ~& p8 m: s* ?Although rarely reported, the widespread avail-+ Q8 j; R( r/ h
ability of androgen products in our society may
$ B# P5 S, W* Y* ?, b5 hindeed cause more virilization in male or female
9 Y( d% C- D5 l( {' ^) Q, Q, Zchildren than one would realize. Exposure to andro-
5 U+ O8 a' O% v; `7 ~9 f2 R1 f$ Cgen products must be considered and specific ques-
' N; S" F6 l3 q) Htioning about the use of a testosterone product or
( Y W) r7 Z/ D; kgel should be asked of the family members during2 b8 q1 l1 R) Y) U4 F& n
the evaluation of any children who present with vir-) V6 D- t5 P, o
ilization or peripheral precocious puberty. The diag-0 R# H( }, M# Z2 h
nosis can be established by just a few tests and by
& W2 J2 t5 m5 W" Vappropriate history. The inability to obtain such a# P* g: ?! b. @: i, \4 y' x
history, or failure to ask the specific questions, may
* P- P) G8 [& ~# G1 G1 O: b bresult in extensive, unnecessary, and expensive
: d$ E; A' G: @4 e& G, [investigation. The primary care physician should be m, w5 N6 J5 V: V! V
aware of this fact, because most of these children. ^: l: A7 y3 S9 N( D5 e" A
may initially present in their practice. The Physicians’8 N6 G P- r: C+ v- L" B# b
Desk Reference and package insert should also put a; j& f. U, U- y- r
warning about the virilizing effect on a male or6 E6 T# c5 E: @* |( I. h$ l+ X
female child who might come in contact with some-
. |) @* x( c7 H/ Q5 Y3 s/ V- {one using any of these products.) K$ J ?, U& O) { k: {: o
References
* L: Z0 I. J$ | X, H+ R1. Styne DM. The testes: disorder of sexual differentiation$ \3 m! r1 F/ q
and puberty in the male. In: Sperling MA, ed. Pediatric/ e5 S1 K) e! G
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) s E* z- W; M8 K' E) |/ k2002: 565-628.$ T0 C/ R* b4 A
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 t0 [7 H& j0 Z* Z
puberty in children with tumours of the suprasellar pineal |
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