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Sexual Precocity in a 16-Month-Old
; d0 H9 q+ _' i8 w" J% hBoy Induced by Indirect Topical! P; A4 K- _, l v9 P$ K
Exposure to Testosterone: E8 i! J" N9 j% q; W6 l
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* _7 ?1 {7 ^) y+ J" A8 x: s
and Kenneth R. Rettig, MD1
/ @) s) Z, T4 {4 _; pClinical Pediatrics
6 i/ L7 V4 o" vVolume 46 Number 6
& y) q7 f+ w- w2 i- J+ E6 tJuly 2007 540-543% j$ y! _0 k6 U V; f- f0 ^
© 2007 Sage Publications9 ^' F* I! G8 ^, c
10.1177/0009922806296651
0 R. w( }. a# U1 n( xhttp://clp.sagepub.com
1 A8 _% b- N' y) n* O, q/ D4 Ihosted at4 n6 O! o3 y7 D4 v
http://online.sagepub.com H' ~9 s" k( Q( @' j3 @3 ] E
Precocious puberty in boys, central or peripheral,0 e* b! c0 ~. q
is a significant concern for physicians. Central
% h$ g- T+ P$ x. N9 Kprecocious puberty (CPP), which is mediated4 ?3 b. w" S7 j7 U ^- A
through the hypothalamic pituitary gonadal axis, has
* s- m |0 u. g4 d% m% ?7 E. {- Y% Ia higher incidence of organic central nervous system% |7 |. K4 S! V* m0 V2 }' Q
lesions in boys.1,2 Virilization in boys, as manifested
# d( O, X! p- k ~; N b% K& Eby enlargement of the penis, development of pubic# K) S N. y) L+ E
hair, and facial acne without enlargement of testi-7 V+ S" S$ L6 K" \
cles, suggests peripheral or pseudopuberty.1-3 We5 [" ^+ b( s8 K$ ?* y
report a 16-month-old boy who presented with the! P6 Q; g1 I3 B
enlargement of the phallus and pubic hair develop-
$ g6 p# t! r3 c8 E5 \$ C& Dment without testicular enlargement, which was due8 c( c$ b2 {, H1 u
to the unintentional exposure to androgen gel used by0 ]& F5 A) o, ]! f
the father. The family initially concealed this infor-
+ x7 ?) O4 g" t: \3 dmation, resulting in an extensive work-up for this3 X) `0 H3 @+ Y1 N, {+ N# e! ^
child. Given the widespread and easy availability of
5 K1 G7 n1 _" g6 K% vtestosterone gel and cream, we believe this is proba-
' p" b( Z! T5 t3 |5 G8 e7 ]bly more common than the rare case report in the
. k2 d# Q. ]! u/ I6 w" E" Pliterature.40 w# \- m2 i$ l4 l
Patient Report
# |2 x! a, z9 ]4 |% Z# _# R0 p' B, C9 t4 zA 16-month-old white child was referred to the) j: ^0 e, p* j# W7 T) t
endocrine clinic by his pediatrician with the concern! M: }4 J* ~, X8 k, z' ~
of early sexual development. His mother noticed
! b4 f) K2 s0 klight colored pubic hair development when he was
1 x# `+ E, r% N. G$ [From the 1Division of Pediatric Endocrinology, 2University of I" `2 P( p5 `8 ?
South Alabama Medical Center, Mobile, Alabama.
* K8 l- J1 Z4 _Address correspondence to: Samar K. Bhowmick, MD, FACE,7 p4 t8 F# [4 k6 w
Professor of Pediatrics, University of South Alabama, College of5 {0 O% Y8 l; e' b' g
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297; g* @9 J7 j( B6 i
e-mail: [email protected].
; x0 ^8 }% ?: m) F5 ]about 6 to 7 months old, which progressively became
: Z: N- e6 `& @$ Ndarker. She was also concerned about the enlarge-9 ^) a+ s6 M9 @$ B% M( O. z' M
ment of his penis and frequent erections. The child
6 N+ o! \, M `. t: N, k8 Ewas the product of a full-term normal delivery, with
/ l- A. H+ g$ Y, Ka birth weight of 7 lb 14 oz, and birth length of
7 f9 |5 e* V8 ]& k20 inches. He was breast-fed throughout the first year0 U& n! k4 D) p6 Z, C5 m% K
of life and was still receiving breast milk along with
9 A7 B" L, @5 l! n: isolid food. He had no hospitalizations or surgery,
+ K9 u; R3 @: z5 Cand his psychosocial and psychomotor development
8 j* }7 [! [8 o$ vwas age appropriate.
% ]5 y* ~+ ]2 _& IThe family history was remarkable for the father,
7 m6 u ~$ n5 Lwho was diagnosed with hypothyroidism at age 16,
& l* V% D" m) ^! _$ c P0 }2 vwhich was treated with thyroxine. The father’s: }# x1 k7 \1 k& b9 H1 n
height was 6 feet, and he went through a somewhat( N0 x! D' O" O8 |6 [! b0 i
early puberty and had stopped growing by age 14.
; C0 j9 v' F g$ mThe father denied taking any other medication. The
5 q& T; q$ l7 Q; I3 \! Ochild’s mother was in good health. Her menarche4 o" z" e$ Y5 k: Q
was at 11 years of age, and her height was at 5 feet: @" E" k( I0 z; s+ s
5 inches. There was no other family history of pre-
; P' D$ y5 H5 l2 ncocious sexual development in the first-degree rela-
* u1 P/ a3 P V1 J- ctives. There were no siblings.: a* i- p- e, v0 o7 n* U
Physical Examination/ |2 }% [7 s! J G! W
The physical examination revealed a very active,
, S5 Z/ m4 f7 r$ d8 r2 o! [) Oplayful, and healthy boy. The vital signs documented7 B9 {( j3 @. n% l% x% {/ Y
a blood pressure of 85/50 mm Hg, his length was" h; @8 O) b: p
90 cm (>97th percentile), and his weight was 14.4 kg
0 j/ Y: Z/ r* u" v6 \(also >97th percentile). The observed yearly growth
0 t6 }" z6 v. ^. {& }1 ~, y( i* Nvelocity was 30 cm (12 inches). The examination of
5 y8 o. E1 n5 Y1 ~: y+ ?" t/ uthe neck revealed no thyroid enlargement.6 L# ^: h: `/ }: K* {
The genitourinary examination was remarkable for
+ g% L+ t3 ?. ?$ senlargement of the penis, with a stretched length of) ]9 i2 U1 R2 D( b
8 cm and a width of 2 cm. The glans penis was very well) G1 P: X: k j
developed. The pubic hair was Tanner II, mostly around% o% j! o" N6 A M! {
540
# \ b2 R' E8 c% @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ r, F! F7 h5 m7 B+ W& T6 `+ y4 |* {the base of the phallus and was dark and curled. The
6 ?: V0 y7 H0 o- }6 C( Z+ C" O. o- f/ [testicular volume was prepubertal at 2 mL each.1 P1 T( \7 n# q
The skin was moist and smooth and somewhat2 U0 Q3 u V7 j; H
oily. No axillary hair was noted. There were no
3 T$ X, t% M: z1 Wabnormal skin pigmentations or café-au-lait spots., _+ W- }$ l1 v! b" a5 `4 F
Neurologic evaluation showed deep tendon reflex 2+
: L% ~! N' b& R. o) L) Z$ zbilateral and symmetrical. There was no suggestion( z# e* \' s7 l
of papilledema.7 {( ]" F' _: }- F+ Z5 H
Laboratory Evaluation
8 F$ t/ {; j: k) xThe bone age was consistent with 28 months by
3 f7 z! y0 C( ^- `using the standard of Greulich and Pyle at a chrono-
' A. w6 B( Z1 l; Llogic age of 16 months (advanced).5 Chromosomal4 `; x7 D- S" K) X
karyotype was 46XY. The thyroid function test
; n5 N3 V8 |1 p; J% Bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-9 y1 V# h9 a0 B5 ]
lating hormone level was 1.3 µIU/mL (both normal). |5 ]" K7 O) V4 d3 N
The concentrations of serum electrolytes, blood8 r8 W7 ?8 F8 b7 c/ q
urea nitrogen, creatinine, and calcium all were
) ^2 \7 b3 m$ @; gwithin normal range for his age. The concentration5 w( E8 \- x) q3 ^# S
of serum 17-hydroxyprogesterone was 16 ng/dL
( P4 J! X3 l. U u2 M(normal, 3 to 90 ng/dL), androstenedione was 20
4 |8 {5 j& \' `ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! _! U0 l3 K! n+ A1 k! m$ vterone was 38 ng/dL (normal, 50 to 760 ng/dL),2 |* a- _* B5 l; l4 ?& W, _/ s
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
3 X, } l4 U- Z3 y) w49ng/dL), 11-desoxycortisol (specific compound S)
- u, Q2 j; d/ b8 ]# A; w+ twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 [$ x; R/ [- N5 v: Htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- v1 {5 a0 j1 F- otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
. r. Q# {) ?1 j0 M3 `% Mand β-human chorionic gonadotropin was less than
, i. J7 R; m4 C4 n5 mIU/mL (normal <5 mIU/mL). Serum follicular; V# { q0 ?* ?$ _
stimulating hormone and leuteinizing hormone
/ [) g1 A9 b/ J) v$ g4 Pconcentrations were less than 0.05 mIU/mL
2 x* t5 c1 f/ Y6 W, j/ d* Q9 ](prepubertal).
7 N" I- f' q+ v) B3 G( ]7 mThe parents were notified about the laboratory' Z, [3 n- W8 H8 T( }
results and were informed that all of the tests were" W/ G6 `* W& {/ Y# }: N& O
normal except the testosterone level was high. The
/ i) {: e8 _5 ~2 ]; tfollow-up visit was arranged within a few weeks to
8 o" i |. U5 h( O/ e1 m7 W( H }9 {obtain testicular and abdominal sonograms; how-
1 E: |2 I8 X5 O( M9 Mever, the family did not return for 4 months.( f9 f) c3 e: E) ]: [! n7 ~
Physical examination at this time revealed that the) j: [& u) }# v8 J
child had grown 2.5 cm in 4 months and had gained
+ s- h |1 Z! \# m9 n0 x* C; N3 @2 kg of weight. Physical examination remained
9 \. @: d% t9 J5 R0 Bunchanged. Surprisingly, the pubic hair almost com-
; ?4 Y) w+ U, v ipletely disappeared except for a few vellous hairs at: d2 _/ U! J1 |' t* w$ {
the base of the phallus. Testicular volume was still 22 H( V& l, d s9 n. d3 a/ G0 H
mL, and the size of the penis remained unchanged.
, N; ~& ^) n3 {# |' AThe mother also said that the boy was no longer hav-
: I, C5 {& \3 o, ~0 V# K+ ^ing frequent erections.
1 Y2 k2 E4 a" F& F) i; vBoth parents were again questioned about use of
. l8 c; [7 x: G3 P8 ~any ointment/creams that they may have applied to) d, a3 S% Q& e0 A. m3 g: t! M* [
the child’s skin. This time the father admitted the
; w L! }2 d# U7 t) yTopical Testosterone Exposure / Bhowmick et al 541
3 [- H# { x* ]/ y& _7 Huse of testosterone gel twice daily that he was apply-
4 o6 j# [- T) a, E- |3 v5 a# S: Ring over his own shoulders, chest, and back area for8 S" x1 g. I0 h4 K- \. t
a year. The father also revealed he was embarrassed
5 J( B1 A) I7 w% Jto disclose that he was using a testosterone gel pre-4 x" o, t9 I+ e z g: ]( D2 v
scribed by his family physician for decreased libido1 d& N" [& ^* }- E A
secondary to depression.5 _" F( y" b+ j2 E. x. J
The child slept in the same bed with parents.+ R) Z d' E' Q' P. A. _
The father would hug the baby and hold him on his t- _0 X5 a% q; V- b) y
chest for a considerable period of time, causing sig-: E) _" u* w, T( R
nificant bare skin contact between baby and father.
# m q" i# H+ T, XThe father also admitted that after the phone call,0 I. p4 B5 `' H" E
when he learned the testosterone level in the baby
! Z! ~4 n; d% `- s7 wwas high, he then read the product information
C o# u5 w+ x* U1 B* b1 qpacket and concluded that it was most likely the rea-7 w: I& {9 U: M P# Y+ {/ |
son for the child’s virilization. At that time, they
3 r6 y; _9 P' M, E" U1 S# Tdecided to put the baby in a separate bed, and the
5 N. |# y1 ]- N% Rfather was not hugging him with bare skin and had. ^( y4 m1 m7 U. `$ X
been using protective clothing. A repeat testosterone E* l+ N; T& ~7 y) P6 Q
test was ordered, but the family did not go to the
4 A0 \8 R% j0 r7 s" j' V! ^laboratory to obtain the test.9 Z9 l0 u- A+ t
Discussion- s8 o$ k2 a0 I: i% i' u# e! r
Precocious puberty in boys is defined as secondary& f7 I! O U6 S' u+ S0 ^
sexual development before 9 years of age.1,4" z+ I$ k' t8 K- p% E" u$ ~% E+ @
Precocious puberty is termed as central (true) when
! \3 t# T! N" r6 | }( b/ `it is caused by the premature activation of hypo-
5 [0 [& z: X' u' ^9 \ V* Z1 a3 \thalamic pituitary gonadal axis. CPP is more com-
9 o. Y; a2 m7 A& R/ S) a) qmon in girls than in boys.1,3 Most boys with CPP1 b" [8 d! [/ A
may have a central nervous system lesion that is& X4 n1 a4 W) b/ E
responsible for the early activation of the hypothal-
5 d, e. y* h! e- {4 g% Pamic pituitary gonadal axis.1-3 Thus, greater empha- m1 b1 V4 v3 k- Z
sis has been given to neuroradiologic imaging in
) C, ?& t9 }0 h% {4 l# Kboys with precocious puberty. In addition to viril-
- F) p9 {" h0 C7 }' @% ~ G( Hization, the clinical hallmark of CPP is the symmet-
, `: c f- c' c2 Yrical testicular growth secondary to stimulation by. x+ M1 U. A/ Y; f5 W
gonadotropins.1,3! c& o7 Y0 d! e4 a8 Y$ }$ h; P
Gonadotropin-independent peripheral preco-
2 t9 L' H0 S. w0 g3 A% y2 W( N! Rcious puberty in boys also results from inappropriate* J7 N* t: X8 Z' g
androgenic stimulation from either endogenous or
. y% W- T; }# w1 r8 p8 A) D+ zexogenous sources, nonpituitary gonadotropin stim-
6 z- T, j) _3 R& wulation, and rare activating mutations.3 Virilizing4 c* V1 Z) J& M6 ^- f
congenital adrenal hyperplasia producing excessive
- Y o# H# d! J% g- r: l5 Madrenal androgens is a common cause of precocious/ ~ B/ w0 B0 ?3 I
puberty in boys.3,4
, Y/ N: N( R4 {3 Z7 O d: b. X* K# fThe most common form of congenital adrenal
" j5 p7 x0 M3 P6 u- q4 Rhyperplasia is the 21-hydroxylase enzyme deficiency.
. p# W4 o0 X. FThe 11-β hydroxylase deficiency may also result in
: p9 @. y3 L# D U R1 Oexcessive adrenal androgen production, and rarely,5 F7 U& ]0 `0 o6 R& e7 J
an adrenal tumor may also cause adrenal androgen0 _+ v: N$ u" ~
excess.1,3
2 G. M! n. C" D/ _1 J5 c! @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ X( Y1 V) T8 q$ ^' D/ |542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; V2 |8 O$ j$ U) w& W& w! UA unique entity of male-limited gonadotropin-) ?, ]. t# v( u) C- ^
independent precocious puberty, which is also known
7 `3 x8 ]+ L" q$ v A- T9 `" Xas testotoxicosis, may cause precocious puberty at a
( k. R- s* r- p+ L" K5 k* Tvery young age. The physical findings in these boys
( Y3 q' C! I$ W' b/ [+ s* X) A- swith this disorder are full pubertal development,( v" x5 A$ {# M! l% ]3 l/ }/ W
including bilateral testicular growth, similar to boys
, o- m/ n* V# B) a. }. H! [7 Qwith CPP. The gonadotropin levels in this disorder
* j A& ~& j) S* f5 a3 Lare suppressed to prepubertal levels and do not show9 B8 ]8 B; E L
pubertal response of gonadotropin after gonadotropin-
* {8 ]5 r) ~! }releasing hormone stimulation. This is a sex-linked- I+ Y9 C& d# k( V6 N) m( N* a& C. U
autosomal dominant disorder that affects only' } ~4 b: L- r: M" ^3 T
males; therefore, other male members of the family
" [5 r* P: ~4 I) A/ x( hmay have similar precocious puberty.3
8 m& D5 e. |4 U6 e+ JIn our patient, physical examination was incon-/ _6 `1 q, _2 c+ n) U, h( I; h2 `
sistent with true precocious puberty since his testi-. l$ s2 C% A) e" O
cles were prepubertal in size. However, testotoxicosis
; D4 P4 D! I2 I+ f' S4 C% \- Bwas in the differential diagnosis because his father! f# c/ D! m% u% ]# d1 U
started puberty somewhat early, and occasionally,
( R l6 W4 D6 a) P4 \1 h& P" U+ Mtesticular enlargement is not that evident in the
: L! d9 \0 a' zbeginning of this process.1 In the absence of a neg-+ T+ H) d: b' r$ R+ A5 P
ative initial history of androgen exposure, our
+ N8 m! D8 k$ R+ H- D; f( |& nbiggest concern was virilizing adrenal hyperplasia,9 q' i* O& w h. E n& ~
either 21-hydroxylase deficiency or 11-β hydroxylase
) K( B' b4 d4 f- [9 N' kdeficiency. Those diagnoses were excluded by find-
1 x, ?: m" T8 u, ring the normal level of adrenal steroids.
) ~& P R( `8 A# `/ [The diagnosis of exogenous androgens was strongly# T% o4 U6 u+ z8 X/ C! O2 G4 A
suspected in a follow-up visit after 4 months because8 W4 J- v# {1 S+ P% z
the physical examination revealed the complete disap-( C: g% k7 j1 z3 S' N8 z1 l
pearance of pubic hair, normal growth velocity, and( z% p1 x" q$ A. y: X7 U2 g
decreased erections. The father admitted using a testos-
4 _( a& _9 A$ h. G: @terone gel, which he concealed at first visit. He was3 N; |, o5 S9 A
using it rather frequently, twice a day. The Physicians’5 U, J5 i% `3 J
Desk Reference, or package insert of this product, gel or. e# Z9 M. L' L
cream, cautions about dermal testosterone transfer to: @+ I$ A) Y* _0 ~& M
unprotected females through direct skin exposure.% z' \" s$ G3 D& Q' w, z
Serum testosterone level was found to be 2 times the, L1 \( Y/ W! r% A* b+ b
baseline value in those females who were exposed to, l. F- P' U' o# s3 K
even 15 minutes of direct skin contact with their male6 Z8 E8 D4 l9 c/ ^: @* x) k
partners.6 However, when a shirt covered the applica-
9 o- }2 F% u3 K7 W7 qtion site, this testosterone transfer was prevented.8 q$ _3 ]. {0 ~1 | ^" X( F
Our patient’s testosterone level was 60 ng/mL,
( ~! r. s& i* ]% r+ s' Cwhich was clearly high. Some studies suggest that
8 ^3 Y j8 o( N, ddermal conversion of testosterone to dihydrotestos-( @1 o8 t( e2 r& I& d
terone, which is a more potent metabolite, is more8 \3 ~) w8 m$ D* \4 w, P/ ~
active in young children exposed to testosterone1 @- I4 G' Y' F
exogenously7; however, we did not measure a dihy-
9 o) j" S, ]3 G0 odrotestosterone level in our patient. In addition to+ ^- G; G. P9 y6 O0 z$ R* V+ j
virilization, exposure to exogenous testosterone in+ s! O; j; c/ b5 d- l0 p$ s4 w
children results in an increase in growth velocity and! c, P, o7 L& ]: }2 A) K( v/ ?
advanced bone age, as seen in our patient.* X, M9 I! t, n+ O: ?
The long-term effect of androgen exposure during: ~* P2 L' A/ p$ W0 Y2 a
early childhood on pubertal development and final7 W1 E& D& F! N' j( `
adult height are not fully known and always remain$ l7 {+ U. C- |% m) G$ |
a concern. Children treated with short-term testos-6 W: l" ~' E* x- m+ }- h5 u* v% Z s
terone injection or topical androgen may exhibit some& ~6 A. {2 y9 ^ d/ v
acceleration of the skeletal maturation; however, after
5 @, [ t0 h+ g+ u! M- Acessation of treatment, the rate of bone maturation
# g( R/ n3 k( P; ?8 D) z% Gdecelerates and gradually returns to normal.8,9* g5 @; J% X& M i% l4 A5 `
There are conflicting reports and controversy% w# f, y+ n$ q, [# J! i
over the effect of early androgen exposure on adult
7 E9 P( _5 A5 T/ |8 e0 _penile length.10,11 Some reports suggest subnormal" _( w/ A# _+ ?5 p3 f, w
adult penile length, apparently because of downreg-8 \6 n, |: m# j2 ^
ulation of androgen receptor number.10,12 However,
9 @' }% S$ X; y0 x! N/ PSutherland et al13 did not find a correlation between& P, r% P- M: @! _
childhood testosterone exposure and reduced adult
4 z2 c+ M* c4 o2 R8 q* ?! M6 l3 cpenile length in clinical studies." `, @3 h' U- C3 i l% v7 e
Nonetheless, we do not believe our patient is
% B0 Q( A. H& q/ Jgoing to experience any of the untoward effects from
$ h# i+ M" F( s" M1 Q: N Wtestosterone exposure as mentioned earlier because
; W% O1 O6 a' v5 M) n( d; Uthe exposure was not for a prolonged period of time.' z8 Q4 r: B7 D. u0 M
Although the bone age was advanced at the time of5 N6 e- Q( I/ m4 s z( y
diagnosis, the child had a normal growth velocity at/ X( v- C2 S+ B) h* V& @
the follow-up visit. It is hoped that his final adult3 {8 {+ `5 P# m' F2 i
height will not be affected.9 U* V4 S9 F. `- Y" v, P" B
Although rarely reported, the widespread avail- i) B3 y0 |7 y; A- P
ability of androgen products in our society may
" b' L2 O5 K! n& k* Vindeed cause more virilization in male or female
3 ?8 u4 c1 u0 H4 P7 Ichildren than one would realize. Exposure to andro-
% @2 [6 w2 I, vgen products must be considered and specific ques-1 H9 f) Y6 ~* U% M; |
tioning about the use of a testosterone product or
$ e6 ?; S; P# b0 c" i/ ygel should be asked of the family members during
6 t9 j7 e3 S6 a6 S qthe evaluation of any children who present with vir-& a9 V7 j: m1 `' ?! o
ilization or peripheral precocious puberty. The diag-7 g* o( v+ A% [0 ~: V5 S) h8 x
nosis can be established by just a few tests and by
5 E3 S1 ~1 a+ s) A* uappropriate history. The inability to obtain such a- m! l `8 T9 Y* \, f2 p
history, or failure to ask the specific questions, may
J- |/ i! G! u. @/ H6 vresult in extensive, unnecessary, and expensive: g* U3 I% z4 Y1 h
investigation. The primary care physician should be* o1 i8 D/ p: l8 D6 _9 N! Z3 i
aware of this fact, because most of these children1 v+ p: I3 w2 [) {
may initially present in their practice. The Physicians’
% D9 [1 E2 h9 [& `4 FDesk Reference and package insert should also put a: R- ?* ~+ e3 ~
warning about the virilizing effect on a male or
' r1 S* T, m: T6 M K, o0 gfemale child who might come in contact with some-
" h( @& \# p, e vone using any of these products.$ Y6 N: A8 R, P) T4 M
References
2 k" t7 L2 o6 G( @$ d8 l& A1. Styne DM. The testes: disorder of sexual differentiation
' M7 R' q- F: ^5 a, Iand puberty in the male. In: Sperling MA, ed. Pediatric; g& G0 j/ }, G/ X" h8 S+ T
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 M! @$ d& B8 f4 v o2002: 565-628.
0 s0 h2 X. T- |# p! \' L' D2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& r8 w' A. x& l: m- u% I& Z
puberty in children with tumours of the suprasellar pineal |
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