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Sexual Precocity in a 16-Month-Old; e1 J6 n g# _% u
Boy Induced by Indirect Topical
: q3 W! `! k7 f: yExposure to Testosterone
; V/ b5 O' |2 g3 {% _Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2 j! U9 k1 @ @: i
and Kenneth R. Rettig, MD1! i& G5 {- ^$ W) k, d# f5 R
Clinical Pediatrics
6 `3 j5 n9 P# o/ uVolume 46 Number 6/ c& k$ Z" n! l. y- J* n
July 2007 540-543' u9 H0 I0 G2 G4 A& g( p
© 2007 Sage Publications) q* ^9 @' t- C
10.1177/00099228062966519 A# J7 x& x3 Q+ {
http://clp.sagepub.com' M% T; R0 A& k7 W5 S, D
hosted at) _% L& v/ E+ n$ B4 S% I5 i7 }, U
http://online.sagepub.com
/ S, Y" P7 p, HPrecocious puberty in boys, central or peripheral,
7 y6 q3 q6 ~) \7 tis a significant concern for physicians. Central" ~1 s% }: w1 O! c" c7 \ {1 d
precocious puberty (CPP), which is mediated
; R; [# R% ?9 A3 R# E R' y$ {, nthrough the hypothalamic pituitary gonadal axis, has. E/ O$ \; x6 c( d
a higher incidence of organic central nervous system, H. z+ R+ Z- s3 K
lesions in boys.1,2 Virilization in boys, as manifested
7 a4 X8 P: F' U7 e0 U' r1 `by enlargement of the penis, development of pubic% [: d% Q; q4 b
hair, and facial acne without enlargement of testi-
, N$ i# K2 e ?/ S( fcles, suggests peripheral or pseudopuberty.1-3 We& l% Q b% Z# X7 ^3 ?" q; \- @+ d
report a 16-month-old boy who presented with the9 }$ Z+ Y1 t/ ]) S- c" C# s
enlargement of the phallus and pubic hair develop-; {- H* a) o5 [" q/ w7 l
ment without testicular enlargement, which was due
3 P* }$ `# T( j7 T9 |to the unintentional exposure to androgen gel used by D6 F, m/ C& {, E' f% m
the father. The family initially concealed this infor-& l" l& t+ {4 H% L2 n0 |
mation, resulting in an extensive work-up for this- F. x4 t$ I( \/ k( N1 F( Y
child. Given the widespread and easy availability of' w: j1 i0 W, s* C
testosterone gel and cream, we believe this is proba-+ G2 p, U/ m+ M7 J' Y
bly more common than the rare case report in the4 r2 I$ D6 b2 k" _
literature.4
& l( [9 V6 B5 M$ c- ~, d; oPatient Report7 p( S* a2 K( Z) X$ x: H
A 16-month-old white child was referred to the: a/ E0 _8 {$ l( j r" v
endocrine clinic by his pediatrician with the concern' ^; B8 `7 [; a/ C8 o) v
of early sexual development. His mother noticed+ X) X2 F, W7 P9 Z* }7 J
light colored pubic hair development when he was
4 F. w% W* O4 `+ @. v e. O# b. RFrom the 1Division of Pediatric Endocrinology, 2University of, j! \$ b! S9 |
South Alabama Medical Center, Mobile, Alabama.( K$ q! {& }; t
Address correspondence to: Samar K. Bhowmick, MD, FACE,
* u- W* ~7 K7 V! FProfessor of Pediatrics, University of South Alabama, College of
# }3 i+ }8 B, PMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;0 ~) z/ O) I, m7 @
e-mail: [email protected].8 C& e# R% ]# n1 z% _' W2 Z. G( T- \
about 6 to 7 months old, which progressively became% V; E' J. w* L8 a- x2 Z
darker. She was also concerned about the enlarge-, b1 k2 W- ~; I5 ~3 K
ment of his penis and frequent erections. The child# Q- }6 \7 X( Q- v4 K
was the product of a full-term normal delivery, with+ ]: X0 `% Q5 [1 J8 w G0 ^7 n
a birth weight of 7 lb 14 oz, and birth length of0 |" i" j& k: b5 B
20 inches. He was breast-fed throughout the first year; ~0 n& e6 h) B
of life and was still receiving breast milk along with
! e5 H* g1 W7 b5 c: m: @( `4 i# }solid food. He had no hospitalizations or surgery,
7 S; c$ R0 `- B# y0 U5 H4 b1 Rand his psychosocial and psychomotor development
" o4 q5 k! B' p' a$ _was age appropriate.
1 N* {1 ~' a* i6 P lThe family history was remarkable for the father,
; W: A, ?9 I0 M8 c. N Owho was diagnosed with hypothyroidism at age 16,4 a/ {1 p+ [& \3 p% g8 Q
which was treated with thyroxine. The father’s
& v3 q* ^ |0 |height was 6 feet, and he went through a somewhat
: n# M; \9 ~* Z& pearly puberty and had stopped growing by age 14.
! z( n0 e' m/ jThe father denied taking any other medication. The$ F7 ^% k( ^+ T
child’s mother was in good health. Her menarche
) e2 x; }$ Z; r1 g, ^9 _6 r) O/ Lwas at 11 years of age, and her height was at 5 feet. v) `6 s' G$ B$ A4 h
5 inches. There was no other family history of pre-
2 [4 J# [( F! D/ [6 J5 lcocious sexual development in the first-degree rela-
- D# w5 x: w0 M5 p/ a8 u" vtives. There were no siblings.
) u0 z+ p" v* J0 |8 U% aPhysical Examination
2 l# z# h4 ~$ Q+ gThe physical examination revealed a very active,+ z0 L+ f) E& C: F. _2 a4 E2 P
playful, and healthy boy. The vital signs documented( P$ c7 S6 O0 M% H3 b$ _
a blood pressure of 85/50 mm Hg, his length was
" ?! R3 o. t0 w1 M/ q$ Q$ P5 e90 cm (>97th percentile), and his weight was 14.4 kg
; Y( p# y/ r* s( R' H(also >97th percentile). The observed yearly growth& n) n: l& z$ L/ }% U
velocity was 30 cm (12 inches). The examination of
; q% }# ]3 b9 X5 v2 j4 r) s/ Qthe neck revealed no thyroid enlargement. M/ U- {5 { f4 U
The genitourinary examination was remarkable for3 P/ j( l3 V( G: q
enlargement of the penis, with a stretched length of
# O. }$ V" [3 O# a( C8 cm and a width of 2 cm. The glans penis was very well) Z! E! v, n; { Z: O4 ]% ?
developed. The pubic hair was Tanner II, mostly around
) a6 ^3 ?! B7 N& u4 J540
# i5 x( ?* b1 \: Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) L' Y+ _- R% Q1 a
the base of the phallus and was dark and curled. The7 T- I% t5 [. O1 k4 y2 X8 A
testicular volume was prepubertal at 2 mL each.* f' Y% x7 D c, f/ P
The skin was moist and smooth and somewhat5 [# r; B4 E0 W% v+ r( u# m
oily. No axillary hair was noted. There were no
3 \7 g3 i/ r0 v3 a: v2 f; j: s8 ?5 C/ zabnormal skin pigmentations or café-au-lait spots.
1 ^" P) M2 R: n# l/ [. E8 ZNeurologic evaluation showed deep tendon reflex 2+
' q/ m* D$ o" y1 C' E; \# @) p* k: ~bilateral and symmetrical. There was no suggestion
% I5 v2 z- J' \: {of papilledema.
# ?" h, y# k" q, s% ?Laboratory Evaluation' f& m3 N2 p; ~( y$ @ g
The bone age was consistent with 28 months by( y4 X, l9 r9 ?0 R$ z
using the standard of Greulich and Pyle at a chrono-
$ X9 w3 y R* x) j2 q% M4 J/ tlogic age of 16 months (advanced).5 Chromosomal
2 Q: F# [! B$ _6 n1 s3 F2 xkaryotype was 46XY. The thyroid function test _0 t; T4 e) N, `
showed a free T4 of 1.69 ng/dL, and thyroid stimu-' \. T, B. L! L$ O7 h
lating hormone level was 1.3 µIU/mL (both normal).
5 Z; t J0 x6 X. E. v+ `& QThe concentrations of serum electrolytes, blood5 }+ B* _8 ~ u9 q
urea nitrogen, creatinine, and calcium all were4 ?" E: i( n0 o4 T! c
within normal range for his age. The concentration Z3 _* q$ U( h: Y/ ]
of serum 17-hydroxyprogesterone was 16 ng/dL6 z9 s. U; _, Z4 b: ~
(normal, 3 to 90 ng/dL), androstenedione was 209 o8 [& A0 {& V' Y+ y" |2 ]
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; u8 X: }0 L' c V
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
. ~7 ^* P* {% Pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ C3 z. @8 m/ `; e! z49ng/dL), 11-desoxycortisol (specific compound S); o; _# k; [4 U: F7 K
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-* V. Q9 F' G7 D* m% s
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
n5 S* V& Y5 H$ Otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 c" {1 k+ D9 \' e7 A. Y2 N+ ?and β-human chorionic gonadotropin was less than
U0 t. t: x: ~! t. l& c- L5 mIU/mL (normal <5 mIU/mL). Serum follicular9 h# c* `& r! f& f9 x
stimulating hormone and leuteinizing hormone
; [) l% U7 q8 ]. Mconcentrations were less than 0.05 mIU/mL7 o5 s1 R# u/ V
(prepubertal).
. D4 Q4 U" c! r5 C! XThe parents were notified about the laboratory* v/ B x8 ^4 I( R9 e7 |2 ~
results and were informed that all of the tests were
- o( w# G0 y1 D$ E2 F( r) Rnormal except the testosterone level was high. The
5 n- A& D9 y- J" ?: Q8 cfollow-up visit was arranged within a few weeks to5 a" s! R' h2 }. D1 V
obtain testicular and abdominal sonograms; how-6 y/ e2 W$ w+ N7 g! L+ S- U: W
ever, the family did not return for 4 months.
2 m% f5 m7 D6 [' cPhysical examination at this time revealed that the* H7 [& @) e( F" x
child had grown 2.5 cm in 4 months and had gained
0 p l3 Q; C. ?" q1 B$ x2 kg of weight. Physical examination remained" j- v! C3 Z8 k
unchanged. Surprisingly, the pubic hair almost com-
9 r) ~6 F$ x& B# Jpletely disappeared except for a few vellous hairs at
) Z" a0 h, ?" d( F0 Sthe base of the phallus. Testicular volume was still 2- |! W j/ H4 j! {
mL, and the size of the penis remained unchanged.( `' T- O1 v, _. x
The mother also said that the boy was no longer hav-% X, ^4 a! p( u8 ]* B
ing frequent erections.
# Y! P! d( H9 KBoth parents were again questioned about use of9 P6 X; z3 R( W) `* T
any ointment/creams that they may have applied to
' T; V* K3 F" W3 l5 sthe child’s skin. This time the father admitted the
/ n, ~6 x6 y: T- F! \5 r6 GTopical Testosterone Exposure / Bhowmick et al 5413 x0 n# Z. ~- ]
use of testosterone gel twice daily that he was apply-" b3 i: B V# d' Z1 P( E8 q u
ing over his own shoulders, chest, and back area for
' ]0 z# X" Y, pa year. The father also revealed he was embarrassed; G7 o' k4 S4 `! x1 c0 v8 ]: W C0 m0 k
to disclose that he was using a testosterone gel pre-
X; G6 [7 O+ Hscribed by his family physician for decreased libido. Z- ?" o9 g m
secondary to depression.
3 Z3 j; G7 r) o5 b& eThe child slept in the same bed with parents.# F. f& \0 n3 @7 w4 w8 P8 `1 t7 T* V8 E
The father would hug the baby and hold him on his8 @+ P: \/ K. h+ o3 M- o
chest for a considerable period of time, causing sig-; _- W2 F9 _) }! i/ K: g
nificant bare skin contact between baby and father.
/ ^/ |0 C3 F3 K9 T# R) n+ vThe father also admitted that after the phone call,
, @' X( i% E' w3 Pwhen he learned the testosterone level in the baby1 C9 E9 C6 q! ]/ u7 F
was high, he then read the product information
. c, E- s9 ^: Xpacket and concluded that it was most likely the rea-! y# }+ r/ \ M, f8 w2 P, \) L' Y
son for the child’s virilization. At that time, they' m' z9 X0 r! X( C/ X
decided to put the baby in a separate bed, and the+ J, a6 Q+ H b0 L1 q# w9 z
father was not hugging him with bare skin and had
4 o; u& d T/ A; N! Vbeen using protective clothing. A repeat testosterone
5 J$ K- t; N8 k/ [test was ordered, but the family did not go to the) U9 Z5 ~8 a( a% K5 p2 }
laboratory to obtain the test.
$ u+ G1 v0 _/ UDiscussion
0 i; a# I" x3 G+ m& jPrecocious puberty in boys is defined as secondary0 q4 O+ _% v. H# Z" h3 L. ]
sexual development before 9 years of age.1,4
5 M* j% y" q) E7 N8 P" l2 }Precocious puberty is termed as central (true) when
: h, {: Q! h! X6 l- {0 y" Qit is caused by the premature activation of hypo-
8 H6 v. x- }+ A; _thalamic pituitary gonadal axis. CPP is more com-
, j& c. r) |' z* I2 u; K& ]mon in girls than in boys.1,3 Most boys with CPP3 T5 d ^0 d5 `- [
may have a central nervous system lesion that is% f, }/ d }! s
responsible for the early activation of the hypothal-. B( W2 q6 d' x3 x) A
amic pituitary gonadal axis.1-3 Thus, greater empha-8 q. _6 O9 |/ a
sis has been given to neuroradiologic imaging in
6 B& T$ r5 F: F1 y) ^boys with precocious puberty. In addition to viril-
4 e) C& \: C: ]$ [" i( Oization, the clinical hallmark of CPP is the symmet-
( i5 |- n. c1 R5 z7 x3 H# Vrical testicular growth secondary to stimulation by
' v: U' G7 R, }* n3 t; Ogonadotropins.1,32 D! L' a$ c, h. b. F5 z9 G6 _: D$ }
Gonadotropin-independent peripheral preco-
9 A* }" g `7 S8 S7 _* o8 B3 h2 a, mcious puberty in boys also results from inappropriate
/ _+ J* d4 e6 G, F0 Wandrogenic stimulation from either endogenous or
' O6 C6 y, A B+ R, s# _2 Eexogenous sources, nonpituitary gonadotropin stim-
1 A+ [& j# I4 k% O- E0 Zulation, and rare activating mutations.3 Virilizing
7 W% b- _( S+ S% \congenital adrenal hyperplasia producing excessive
/ X* F3 _. B& f5 S4 g3 Hadrenal androgens is a common cause of precocious' V4 m9 c1 m- p) B, k$ {
puberty in boys.3,4
! V4 h) g& a3 v* C4 a* [0 S) XThe most common form of congenital adrenal
2 Q- H: T( y- I8 y7 s ^6 H; chyperplasia is the 21-hydroxylase enzyme deficiency.
& Q; z: {7 Z* |9 yThe 11-β hydroxylase deficiency may also result in& G* C+ M% s* r
excessive adrenal androgen production, and rarely,7 m5 Z3 Z" E5 D+ Y w
an adrenal tumor may also cause adrenal androgen0 s N/ P* h# O* j! n+ H" v
excess.1,3
- [8 @ U, {% X. z5 Sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 I% l- c& l3 ]' l. I0 {542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. b* a! \# [1 }# k/ N
A unique entity of male-limited gonadotropin-( c! X7 K+ {4 F c8 Q5 S4 y
independent precocious puberty, which is also known) i& {, `) B2 y, r: f0 O' k+ f* D. D
as testotoxicosis, may cause precocious puberty at a0 `' h; w( W3 {- A, ~. ?6 ~" Z
very young age. The physical findings in these boys
" y0 E3 _8 X7 U \, R( Nwith this disorder are full pubertal development,* p( @8 |& O$ g) }6 I
including bilateral testicular growth, similar to boys
. I( y; B7 }2 i! @' D/ Hwith CPP. The gonadotropin levels in this disorder
# z( Q- d q* A5 k" d# b" qare suppressed to prepubertal levels and do not show
2 h* F1 m) H+ M* W- J9 D0 w* }pubertal response of gonadotropin after gonadotropin-1 c$ B" s- s& Z2 Y& J; b3 j
releasing hormone stimulation. This is a sex-linked
( J1 Q( H. U" c5 w2 H5 G5 iautosomal dominant disorder that affects only
2 m: X' C, _4 ]3 V- D5 i' umales; therefore, other male members of the family7 r6 k# J* ]/ B6 k2 B+ Q/ V8 m5 d
may have similar precocious puberty.3
) a7 A c+ j$ i2 ?+ h; K& U( ~ XIn our patient, physical examination was incon-
- f+ O, `9 b1 @4 R. l8 D+ Osistent with true precocious puberty since his testi-
6 g4 a+ J4 X& D, @$ Pcles were prepubertal in size. However, testotoxicosis
8 }3 o' ~' T7 E- mwas in the differential diagnosis because his father2 p# R3 a5 P# T4 N
started puberty somewhat early, and occasionally,
E% A5 V8 y) V& Y+ }* ?testicular enlargement is not that evident in the1 q8 F7 }1 \5 T8 C& _8 C
beginning of this process.1 In the absence of a neg-
" X& e0 E1 e2 F* q( [) J3 y' hative initial history of androgen exposure, our
# @2 ^. {! R( B. i: S/ Q5 D3 w' [biggest concern was virilizing adrenal hyperplasia,5 K; j5 e) T2 r6 N; u* p
either 21-hydroxylase deficiency or 11-β hydroxylase
) h T3 `4 w& m5 o& zdeficiency. Those diagnoses were excluded by find-
# T' R3 ?4 {9 c. M" f9 F7 ting the normal level of adrenal steroids.3 I& k, p. q9 `4 h3 s" @7 w
The diagnosis of exogenous androgens was strongly
: a. [, K/ g; [/ W5 l! Csuspected in a follow-up visit after 4 months because/ F4 R: k0 d# r. a+ a* x
the physical examination revealed the complete disap-
( Y% B4 ~3 l) ^) C7 x- A" Xpearance of pubic hair, normal growth velocity, and% V4 u! d6 `# g s( K3 s" [
decreased erections. The father admitted using a testos-
& S- X$ b" P1 [* J5 N) ^- Sterone gel, which he concealed at first visit. He was
1 M5 ~: }! x* v G+ }3 p0 |using it rather frequently, twice a day. The Physicians’5 g; s- E# I1 M1 |, ?$ E* t
Desk Reference, or package insert of this product, gel or
+ }+ F% n7 @( X+ fcream, cautions about dermal testosterone transfer to
& D9 _3 N( W$ ?7 m9 p* Vunprotected females through direct skin exposure.* N1 _: m# ?: R/ Q6 x
Serum testosterone level was found to be 2 times the
$ _, `' H0 L N& I. ebaseline value in those females who were exposed to
& D/ s% }, `: K% f: r' Weven 15 minutes of direct skin contact with their male" W7 M* B; Q0 q1 [, ?! O+ L
partners.6 However, when a shirt covered the applica-3 X, P9 ]3 s; f; o
tion site, this testosterone transfer was prevented.' k+ m4 d. [2 U6 I6 \1 K
Our patient’s testosterone level was 60 ng/mL,& `" O$ U; e" [1 g a% I+ o% h
which was clearly high. Some studies suggest that
+ N+ ]3 C% |4 Q: J2 F, I" Gdermal conversion of testosterone to dihydrotestos-
4 ]" h$ K2 B1 @terone, which is a more potent metabolite, is more9 V- T* I0 A: ]
active in young children exposed to testosterone
7 c: L" E, r0 S" Y9 C7 q- B$ kexogenously7; however, we did not measure a dihy-! Y" y( |+ p2 W2 b
drotestosterone level in our patient. In addition to7 a8 Q( a5 @4 W0 X9 U: V
virilization, exposure to exogenous testosterone in4 g, y/ E% q& y6 T5 A
children results in an increase in growth velocity and
; O) ~! n, C& q0 u- ]$ ]0 Dadvanced bone age, as seen in our patient.
/ _+ O- e0 L: E. Y' hThe long-term effect of androgen exposure during# m% e+ \0 @1 N3 }, y4 ^# A4 a
early childhood on pubertal development and final
S) ?4 j' |$ ?1 P8 K* \9 _adult height are not fully known and always remain1 A( E, I* ?; d: l+ v5 d: F
a concern. Children treated with short-term testos-/ @3 q- w* A: a; H' g U
terone injection or topical androgen may exhibit some
- n. T! H: ^) Z6 Zacceleration of the skeletal maturation; however, after
- r9 w7 p$ E1 ?" R3 P$ wcessation of treatment, the rate of bone maturation
5 I- J/ |; J& w, f) Ndecelerates and gradually returns to normal.8,9/ v7 p7 _+ u6 d, E$ b8 O
There are conflicting reports and controversy
7 c1 K" t+ q) m' M r/ ]over the effect of early androgen exposure on adult
# T) O- J; i6 ]8 tpenile length.10,11 Some reports suggest subnormal( X. w5 J& e& H+ J2 w& m
adult penile length, apparently because of downreg-
2 _3 u. Z3 X# ?, Oulation of androgen receptor number.10,12 However,& {6 Q# }9 o8 F; y: Z Z6 Q+ [
Sutherland et al13 did not find a correlation between
4 _" b3 U% l/ l3 n. ichildhood testosterone exposure and reduced adult% O* Q* S/ H5 ]( v) s
penile length in clinical studies. I# h5 |8 k* ^- i2 h
Nonetheless, we do not believe our patient is7 @# f2 P8 @: G! f
going to experience any of the untoward effects from. w" T8 q( q2 i; g8 D* R
testosterone exposure as mentioned earlier because, v! t. p) { X! A" p5 P( ]; Y
the exposure was not for a prolonged period of time.
W8 i! l- [: p4 Q: S, N) B HAlthough the bone age was advanced at the time of
) E1 C. {% [! Z7 C; ]+ gdiagnosis, the child had a normal growth velocity at8 b9 b! }5 o$ L; J
the follow-up visit. It is hoped that his final adult
3 S/ M7 g' c1 _' o" Theight will not be affected.2 G& A. l, @3 J5 b$ f% w
Although rarely reported, the widespread avail-+ @, u) U! ~- q4 i+ V- \
ability of androgen products in our society may
$ z' u, |+ R4 D7 v: E' cindeed cause more virilization in male or female, i# c9 F, ]; V9 d0 f
children than one would realize. Exposure to andro-
0 D9 M+ Q7 e- D: Z' d+ [6 ngen products must be considered and specific ques-
R0 z( s3 y! U3 c3 p. @tioning about the use of a testosterone product or
) l# j6 U& ?8 X! o5 Tgel should be asked of the family members during% T2 h0 w% Q. a2 |2 S, L( k" R6 \
the evaluation of any children who present with vir-; x: a, f5 t: e+ z( _' b
ilization or peripheral precocious puberty. The diag-5 p, J) v2 B: |
nosis can be established by just a few tests and by R& z- H+ B0 H
appropriate history. The inability to obtain such a$ @1 J4 s) K( F% A( ~( ~' H* j
history, or failure to ask the specific questions, may; B0 j; ~- d, a% p( Y% k, r! a3 z
result in extensive, unnecessary, and expensive
6 |' [; Q( u0 | t" S; K7 n7 T$ ]7 O/ ~investigation. The primary care physician should be
) c: _$ j" C/ d% U1 ^1 K3 D6 Z" c# oaware of this fact, because most of these children# E0 V+ F8 r! t* O- g& ?
may initially present in their practice. The Physicians’
`+ m# X. N; k% N7 h2 ^' @Desk Reference and package insert should also put a5 E. |8 x3 O# `7 |# r
warning about the virilizing effect on a male or
9 r! U! E6 e7 }# afemale child who might come in contact with some-! r; p$ W* |" A& }- K% `
one using any of these products.& l" }& H+ _$ Y( D, J
References
- S5 e2 U# e; s% b/ r& G8 G1. Styne DM. The testes: disorder of sexual differentiation* k& W2 r9 r( p+ C x( R8 L
and puberty in the male. In: Sperling MA, ed. Pediatric: _" V2 L2 E! D7 l
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 v3 I, |0 q, S9 p( d2002: 565-628.2 B+ I+ u" _7 i; A1 a8 J W
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& e' m2 b, o& A+ P3 b$ `1 Spuberty in children with tumours of the suprasellar pineal |
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