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Sexual Precocity in a 16-Month-Old2 K% J" G8 G! K0 G" V( R
Boy Induced by Indirect Topical8 g/ s6 W. P" Z. r% r
Exposure to Testosterone; A) q1 J/ |# o( }) Y
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* o) \2 U# F7 {4 W7 a1 }
and Kenneth R. Rettig, MD10 i, R+ \; u: E2 }
Clinical Pediatrics s6 d0 `# {8 k8 l& {
Volume 46 Number 61 q4 P7 M! @" ]+ f
July 2007 540-5437 c C# S: X% L6 m! @9 H b
© 2007 Sage Publications+ C% [. F3 ?8 l( v
10.1177/0009922806296651$ c) _& G5 n5 V1 N: Q
http://clp.sagepub.com0 o6 p) j3 F( k+ E5 @
hosted at/ M9 `$ ]& g) X- e6 l
http://online.sagepub.com% ]9 k- C( e8 b/ q7 A: ^
Precocious puberty in boys, central or peripheral,
p! H4 f Q- U1 T* lis a significant concern for physicians. Central
/ g; P2 q+ S1 j" gprecocious puberty (CPP), which is mediated
N+ [8 [. b, p; ~+ rthrough the hypothalamic pituitary gonadal axis, has
: s; e0 S* b2 L, N* O$ Fa higher incidence of organic central nervous system6 T' ^ m" a" T7 G; M
lesions in boys.1,2 Virilization in boys, as manifested
0 _8 `6 Z. ?" tby enlargement of the penis, development of pubic# `' C, _) Y' J( _
hair, and facial acne without enlargement of testi-
* g/ ~0 T* W7 q- U ?8 rcles, suggests peripheral or pseudopuberty.1-3 We
) x( L& }( }$ \/ h) Sreport a 16-month-old boy who presented with the: C ~+ Z% Y$ h/ L9 p0 c' G
enlargement of the phallus and pubic hair develop-1 E$ t1 f' z4 r4 k$ c, y, { Q, U! @
ment without testicular enlargement, which was due4 M% i' Z$ a3 E0 S
to the unintentional exposure to androgen gel used by
' D# B N, k" ?, k! O/ H* u, zthe father. The family initially concealed this infor-
; e4 q9 p% U5 w2 g7 H- m: tmation, resulting in an extensive work-up for this* t* D$ X7 |3 P3 p4 B
child. Given the widespread and easy availability of- P m, F' \+ P; l! N6 ~
testosterone gel and cream, we believe this is proba-6 ~9 p; U; i. V2 c5 S5 L
bly more common than the rare case report in the
; U( k+ @0 b" Pliterature.4; [8 D8 a. D2 s
Patient Report
( t: ^1 e9 Q" z& s, U2 SA 16-month-old white child was referred to the, c, o4 }" O( Y) c7 A5 _$ v
endocrine clinic by his pediatrician with the concern
1 d8 ^( n8 |9 T( S: d/ S: Cof early sexual development. His mother noticed
$ ?" H5 K+ }- H8 R9 o8 ulight colored pubic hair development when he was/ v5 h. j0 J' P% R7 z
From the 1Division of Pediatric Endocrinology, 2University of F, x- U; N5 r, I3 f3 S
South Alabama Medical Center, Mobile, Alabama.
( ?6 y$ S! ]/ tAddress correspondence to: Samar K. Bhowmick, MD, FACE,8 u$ _! L" Z% R8 ~' l
Professor of Pediatrics, University of South Alabama, College of
) K. q5 U8 H4 d1 FMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
( {. n3 k( H0 \! X& C6 e6 Ke-mail: [email protected].
% M- ]; Z" V; g* I8 j" U& cabout 6 to 7 months old, which progressively became" Q3 j x$ `3 }4 s. Z
darker. She was also concerned about the enlarge-
5 T; [: O {/ e0 h% Kment of his penis and frequent erections. The child
( d( a6 ]( @/ w2 nwas the product of a full-term normal delivery, with S* D- a k. [0 V3 A( x) Q
a birth weight of 7 lb 14 oz, and birth length of
, _# |7 s9 u6 ^20 inches. He was breast-fed throughout the first year& t! { r" N+ i/ a
of life and was still receiving breast milk along with
: ]+ _) z U- v8 w# Q1 F3 ssolid food. He had no hospitalizations or surgery,
# t5 N0 H, K! a3 f9 {and his psychosocial and psychomotor development
" V+ M0 F1 v3 ?! x' I5 Rwas age appropriate.8 V' X/ S: |4 p
The family history was remarkable for the father,* v; o' R7 N! A* F1 p1 u7 W
who was diagnosed with hypothyroidism at age 16,7 Q t4 a3 m) p
which was treated with thyroxine. The father’s- N& p6 M& |1 S! k. }9 \
height was 6 feet, and he went through a somewhat3 w7 o; i" D1 T& I) S, v
early puberty and had stopped growing by age 14.
, E* V" E* q# h# _# q# }- E) HThe father denied taking any other medication. The9 q8 F+ S( w# N, V4 K; K
child’s mother was in good health. Her menarche# j& v" g& l0 _" W9 o+ [5 r Y+ I
was at 11 years of age, and her height was at 5 feet
8 R2 ~) ^! A* [5 inches. There was no other family history of pre-5 a0 C. y. u" v, v
cocious sexual development in the first-degree rela-
9 V: {2 H; j% ltives. There were no siblings.
! u5 n/ b" b! \6 K- ~Physical Examination* H$ v! i5 d" ^. L1 J# M5 ]& k
The physical examination revealed a very active,2 y/ x+ A+ ~3 B: c: i2 s$ r- [ o
playful, and healthy boy. The vital signs documented
) Z, Q# L* |8 o# `+ ~$ f' c& ca blood pressure of 85/50 mm Hg, his length was W7 q0 [0 G0 b+ I
90 cm (>97th percentile), and his weight was 14.4 kg# J6 U* f* h3 t9 j. G
(also >97th percentile). The observed yearly growth. a' D) w# Z* ^ d+ a4 I9 J+ U5 U
velocity was 30 cm (12 inches). The examination of
! K$ z) F, l) H! nthe neck revealed no thyroid enlargement.+ j4 i" O+ Z0 y6 S0 }; H
The genitourinary examination was remarkable for0 ]: q' ?2 K7 w2 {8 J' q4 T
enlargement of the penis, with a stretched length of0 \1 K. U( f" r8 K' X7 n
8 cm and a width of 2 cm. The glans penis was very well4 s2 q4 T! S& O. z
developed. The pubic hair was Tanner II, mostly around
9 ]3 |9 c2 f' `8 M* f; j540! i4 i1 E' X2 l! G3 L
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 E' s- ~$ K& l* \( F/ _% h: w: t
the base of the phallus and was dark and curled. The
, W, ~8 f$ ^- B \) O. V/ ?! M& f9 X/ gtesticular volume was prepubertal at 2 mL each.
! y% B7 A' |+ S: q8 @The skin was moist and smooth and somewhat
+ U; \# T) Y4 y' w$ t! aoily. No axillary hair was noted. There were no; X, ]5 f9 I9 }8 |
abnormal skin pigmentations or café-au-lait spots.5 M: p' @: ^# j( b
Neurologic evaluation showed deep tendon reflex 2+2 _$ Z: t8 i0 r% n/ X6 V
bilateral and symmetrical. There was no suggestion
( c4 S3 w. O1 A7 w6 ]0 k, Nof papilledema.
4 F- F# x- d2 }% q; aLaboratory Evaluation4 k! _# `" e, [& p; ^; C3 |
The bone age was consistent with 28 months by
0 Z& _( F4 n# I7 Qusing the standard of Greulich and Pyle at a chrono-' g; s7 i6 C' o
logic age of 16 months (advanced).5 Chromosomal
' s% H/ a% Y* B: s7 Z {karyotype was 46XY. The thyroid function test6 e( X7 o9 ]# n5 L- ~
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 B( M7 m. U0 n* b" wlating hormone level was 1.3 µIU/mL (both normal).
: _* v1 z6 c8 E1 X3 U; g# {The concentrations of serum electrolytes, blood
7 G% O& M8 j' s V2 Surea nitrogen, creatinine, and calcium all were
/ G4 J1 q1 p$ c) f/ q, W0 ]! cwithin normal range for his age. The concentration+ P' T! ?( D) T- |* z
of serum 17-hydroxyprogesterone was 16 ng/dL
3 `) s; z( s" {(normal, 3 to 90 ng/dL), androstenedione was 20
+ u, T3 y6 B' P* Dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-. ^% e( s+ w! c) @% J5 }+ W4 l
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
3 ]: y* ]+ V; ^! F( [" Mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
1 V- I; y0 ~3 Y' l" o49ng/dL), 11-desoxycortisol (specific compound S)& A- i7 e) S( u* v* G; @' V
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 ?, N/ Z! ?8 d( V, B; y) r2 X& etisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. n4 o# c" g t2 N3 N. G4 q U
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& f( f* D( r+ W' b( U+ Xand β-human chorionic gonadotropin was less than
# U, ?2 I) {: i: j" g5 mIU/mL (normal <5 mIU/mL). Serum follicular
+ Q9 N1 F- ]( Dstimulating hormone and leuteinizing hormone, `& g* {. V9 T5 g* x2 M0 U
concentrations were less than 0.05 mIU/mL
4 x- v3 |, u d8 j5 M$ D- ](prepubertal).
0 l" }" m# e0 L4 G# k" d+ pThe parents were notified about the laboratory ?9 H5 _' x" t
results and were informed that all of the tests were
* r2 r6 Q w3 V& s( J2 T' cnormal except the testosterone level was high. The. D4 l6 ^( r1 h0 ^( {
follow-up visit was arranged within a few weeks to
6 E$ j& o- E- q6 mobtain testicular and abdominal sonograms; how-! b2 H2 p: O, C) H3 x
ever, the family did not return for 4 months.* H7 n$ }: _4 C* [) ^5 v, @6 f. n6 |
Physical examination at this time revealed that the4 M& l* l/ r4 D6 q8 }% d9 z1 Z7 L
child had grown 2.5 cm in 4 months and had gained1 g$ O6 e+ Q8 S; K8 D# O
2 kg of weight. Physical examination remained
) P. A: i4 ^6 |0 C0 ]% sunchanged. Surprisingly, the pubic hair almost com-" X: T2 M4 L# X' L
pletely disappeared except for a few vellous hairs at/ Q+ S% P* b( Q5 M( l+ k& [! R6 H5 n
the base of the phallus. Testicular volume was still 2
0 X, k7 {, O9 O3 d* lmL, and the size of the penis remained unchanged.
C2 A [) n5 FThe mother also said that the boy was no longer hav-
+ k! X! d' R c& b! |- ning frequent erections.3 g1 l# q+ R* o8 A9 |
Both parents were again questioned about use of N5 a+ A5 p" ^* V0 ^' C; t
any ointment/creams that they may have applied to' N2 Q/ Z/ L& k4 e4 s
the child’s skin. This time the father admitted the
1 }; Y9 b, X( H& xTopical Testosterone Exposure / Bhowmick et al 541
4 }; {" }% B' S/ I$ Juse of testosterone gel twice daily that he was apply-
: q P$ a. ^( A( ^' s1 |. iing over his own shoulders, chest, and back area for* d' |5 l6 [, Y
a year. The father also revealed he was embarrassed
! a y* p0 b9 p; _. Y' Zto disclose that he was using a testosterone gel pre-
; E. ]2 ?* j* O) l% a$ i n# \( g% ?scribed by his family physician for decreased libido
, J8 Q4 \9 {& h$ ]: x6 Osecondary to depression.: Q) e) i K2 y+ T
The child slept in the same bed with parents.
% l; N$ [/ n! s0 F% bThe father would hug the baby and hold him on his6 ^ j$ \/ g/ v, f- o
chest for a considerable period of time, causing sig-
7 a+ E3 i {7 [9 Anificant bare skin contact between baby and father.
6 u: r8 e3 X& q1 O5 P' oThe father also admitted that after the phone call,0 M5 D: v4 _8 I8 g) W0 `" |
when he learned the testosterone level in the baby: E4 _) x2 b. P/ b: k" @
was high, he then read the product information2 c* {& ?( V. W# ^/ g. S1 [7 A- z
packet and concluded that it was most likely the rea-
4 z; y, O$ M6 b7 c+ f7 lson for the child’s virilization. At that time, they
- P& j' b1 f* Q4 Q Edecided to put the baby in a separate bed, and the
6 J& S+ D& v, `father was not hugging him with bare skin and had
8 e; S' A' { _$ {, {( f) f( Ibeen using protective clothing. A repeat testosterone1 X, ~' ?( z" d
test was ordered, but the family did not go to the1 @# M6 s8 j' u, U, F# X ~
laboratory to obtain the test.) E7 ^% @. L4 u( x2 @6 D r' U
Discussion! F& E8 h, t9 ^8 J
Precocious puberty in boys is defined as secondary# Y5 J& y; s1 F$ w. l5 A6 i
sexual development before 9 years of age.1,4) w9 v% ~3 y3 P7 W
Precocious puberty is termed as central (true) when
( `, C; x7 {2 A7 u! H+ i# {it is caused by the premature activation of hypo-
5 C- [8 g5 s: [- q; Pthalamic pituitary gonadal axis. CPP is more com-
2 p' n7 X9 ^" Z# Umon in girls than in boys.1,3 Most boys with CPP |8 n4 u# d# z: I& z/ S* M
may have a central nervous system lesion that is
9 T, s: g% k8 S) ^* ^! R9 wresponsible for the early activation of the hypothal- l' \7 ^7 Q( V3 d
amic pituitary gonadal axis.1-3 Thus, greater empha-% n, ]% g+ k: [4 j
sis has been given to neuroradiologic imaging in
) t5 k! A9 n( k6 _4 f2 C; Jboys with precocious puberty. In addition to viril-
5 s- [$ e+ n# }4 m' Y# v' o5 k! Lization, the clinical hallmark of CPP is the symmet-
+ K; @8 U2 e& c% b. R, P, m+ Y% Prical testicular growth secondary to stimulation by
. W, T2 D+ y# R3 P' l: R6 Rgonadotropins.1,30 C- O- T5 z T/ ]( t( e
Gonadotropin-independent peripheral preco-7 P) |1 M" \) r8 ]- F" x2 { G/ A
cious puberty in boys also results from inappropriate0 l0 T' A ^( ~
androgenic stimulation from either endogenous or! G0 q6 L3 y5 y* y
exogenous sources, nonpituitary gonadotropin stim-
4 p% \4 T9 I$ `) L5 M# Vulation, and rare activating mutations.3 Virilizing: b T; H6 S% d! g4 e
congenital adrenal hyperplasia producing excessive
; m* n O: i+ @2 V& dadrenal androgens is a common cause of precocious, J. K1 X1 O% S1 ~/ f+ q8 H) b3 C
puberty in boys.3,4- A7 Y. F+ x6 {% D* h1 V
The most common form of congenital adrenal% [& n0 }3 o$ L" l0 b
hyperplasia is the 21-hydroxylase enzyme deficiency.
5 K, `* m# x2 t4 rThe 11-β hydroxylase deficiency may also result in
/ Q; ?+ h7 L/ b9 jexcessive adrenal androgen production, and rarely,
$ L4 P& F% I& H# ]an adrenal tumor may also cause adrenal androgen6 C3 K/ w0 t! D$ l; z+ ]& x
excess.1,3
5 n6 D5 z3 x" _( p/ ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% Z7 l7 y' k6 g& K. i1 M542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& ^6 r# r, B p$ j: ~" c3 bA unique entity of male-limited gonadotropin-0 H$ c1 @/ [0 m& h
independent precocious puberty, which is also known6 n$ @# c! W* M& V5 v+ E# U
as testotoxicosis, may cause precocious puberty at a/ e# w/ k# R g1 y3 @* d# ? _
very young age. The physical findings in these boys
/ R' c) [0 J% ^with this disorder are full pubertal development,
- y+ f" F _/ |* t& E! Mincluding bilateral testicular growth, similar to boys
' o/ |) C/ t8 a% \, |$ @( Bwith CPP. The gonadotropin levels in this disorder
: J& y: e4 B9 x3 ware suppressed to prepubertal levels and do not show
! g) P& Q$ i2 f- ]- H- Hpubertal response of gonadotropin after gonadotropin-- e4 Y% w) Q% z! F4 `. F B
releasing hormone stimulation. This is a sex-linked
+ a6 V( L4 x9 t; nautosomal dominant disorder that affects only
9 b' ~* @* F" f2 Tmales; therefore, other male members of the family
0 X& D4 ?' E' n z" Fmay have similar precocious puberty.3
3 Y z- J0 i0 F) |7 n: S1 A( i) TIn our patient, physical examination was incon-. g* C& d. x* X/ @1 g/ u5 s# A- o
sistent with true precocious puberty since his testi-0 k+ e1 _# Y, C$ v8 Y
cles were prepubertal in size. However, testotoxicosis
; @5 m3 E- H9 Swas in the differential diagnosis because his father
, | |* {' b; W5 L" N0 }$ a: Ystarted puberty somewhat early, and occasionally,6 V) K# Q1 Y$ E6 c
testicular enlargement is not that evident in the. {. V9 U: a0 w( @' d
beginning of this process.1 In the absence of a neg-
& @& c$ n( `6 Native initial history of androgen exposure, our- s+ ?% H$ j( X; \2 ]+ H
biggest concern was virilizing adrenal hyperplasia,
; p4 b+ Z: ^* O" \6 S% @# }either 21-hydroxylase deficiency or 11-β hydroxylase
8 _* P4 F( q' j* wdeficiency. Those diagnoses were excluded by find-
e* H% u" U) v7 @0 Ning the normal level of adrenal steroids.
! T/ c+ L3 q' ?' [. V# I/ R" UThe diagnosis of exogenous androgens was strongly
3 ]! d$ \; W# z, jsuspected in a follow-up visit after 4 months because
# M `) F- o2 A8 u2 H- z6 z2 zthe physical examination revealed the complete disap-
# r- [5 {6 f( S6 b5 v$ D$ Vpearance of pubic hair, normal growth velocity, and) }) M. F/ \1 W B
decreased erections. The father admitted using a testos-
$ X( X* K! F; o; Aterone gel, which he concealed at first visit. He was
- n4 O0 s5 ~( f6 Jusing it rather frequently, twice a day. The Physicians’4 e& a' ]) @% ?' N8 a
Desk Reference, or package insert of this product, gel or
9 i* M n* t* P( ?& ucream, cautions about dermal testosterone transfer to
* @# k$ E( c) k: g9 i# K1 Xunprotected females through direct skin exposure.
/ O" B: ~7 m" R2 X$ Z2 N, B4 e" wSerum testosterone level was found to be 2 times the1 M+ R2 S, x8 `# f
baseline value in those females who were exposed to: _9 E( ~, F# A5 y9 r; g
even 15 minutes of direct skin contact with their male- f. @( w1 m# l9 S3 u
partners.6 However, when a shirt covered the applica-
' ?7 R! L8 J8 }" M+ u, P. F9 ction site, this testosterone transfer was prevented.
! G# v, h' H* u* L* ?$ r: B" h4 HOur patient’s testosterone level was 60 ng/mL,+ I1 p# q0 a% R d% ]
which was clearly high. Some studies suggest that& H7 ~* f: v6 l! X
dermal conversion of testosterone to dihydrotestos-1 W5 ? U/ o2 Q/ `! o
terone, which is a more potent metabolite, is more. m* A( _- e/ M2 e8 q6 D) M
active in young children exposed to testosterone
% t: l4 d8 v! I$ j; p/ Aexogenously7; however, we did not measure a dihy-
( M. C' i/ r& N5 {1 _7 a5 I# Kdrotestosterone level in our patient. In addition to* F1 n0 |; _' j
virilization, exposure to exogenous testosterone in
* B: a+ [* i* \ d% Dchildren results in an increase in growth velocity and O4 b5 f0 F/ I; L+ F1 u
advanced bone age, as seen in our patient.
0 T6 G( V+ j4 ]The long-term effect of androgen exposure during
" W/ h' ^' J- X! `early childhood on pubertal development and final
3 R0 |6 u" W% Z/ W' }; ]! `& radult height are not fully known and always remain' J& n5 ?1 Z0 v( i) m
a concern. Children treated with short-term testos-6 e0 f3 }" v0 B8 ?. i( e# T
terone injection or topical androgen may exhibit some
- K4 s+ I' D% D% m- j, C6 f: Kacceleration of the skeletal maturation; however, after
7 L7 V* ]7 t2 p7 F+ Qcessation of treatment, the rate of bone maturation. |9 ]! N9 h$ W" F
decelerates and gradually returns to normal.8,9
& I* v- d- `) XThere are conflicting reports and controversy
+ a+ d: ~( ^ A! tover the effect of early androgen exposure on adult
5 N! V7 e* \4 t6 J6 ?/ wpenile length.10,11 Some reports suggest subnormal
3 f0 B, p; b4 }* F, g1 Radult penile length, apparently because of downreg-
b% ]: I& C7 b! M9 F! N: mulation of androgen receptor number.10,12 However, \/ Z. P( k2 y/ v; v
Sutherland et al13 did not find a correlation between
4 W; P0 J8 K& v) F2 }$ ^+ m3 `childhood testosterone exposure and reduced adult- p( v( C/ J* O; N: D( S
penile length in clinical studies.
- j1 ^, P4 r. H, z- a% y. l1 XNonetheless, we do not believe our patient is
* \0 S9 e1 H, F* A; \- m+ Ugoing to experience any of the untoward effects from! E: |" @8 Y% U4 S, z1 F
testosterone exposure as mentioned earlier because
4 G* d. l6 t# y% a* A/ @the exposure was not for a prolonged period of time.6 p: K% X/ c, ]( \: r! j7 w
Although the bone age was advanced at the time of
2 g4 ^5 z8 V: T: Ddiagnosis, the child had a normal growth velocity at
) x( s4 B" u0 X X& g& P9 ]' D: Hthe follow-up visit. It is hoped that his final adult0 \; w7 d/ G d, q0 H
height will not be affected.
! T) ]2 a, V) E0 C4 d/ V; `Although rarely reported, the widespread avail-1 ~ w$ g! a2 @9 Z
ability of androgen products in our society may5 p8 z- m# X1 t
indeed cause more virilization in male or female
" Z j' A+ Y3 u, qchildren than one would realize. Exposure to andro-
$ r; U1 p. h( D: ~0 i% J5 _gen products must be considered and specific ques-
" T3 }- W5 i3 Z& Htioning about the use of a testosterone product or
. o* m7 M% I- z. `+ j) O3 v" ugel should be asked of the family members during
# j0 n# i9 ] _! s3 X& o$ [the evaluation of any children who present with vir-
8 G8 q0 ~, O" ], e, Q1 {ilization or peripheral precocious puberty. The diag-
, D$ K% E6 o' unosis can be established by just a few tests and by
/ b, c0 `. [# m- J( w& Iappropriate history. The inability to obtain such a1 I( u" c, G; |7 d& Q/ W! p' U
history, or failure to ask the specific questions, may
8 @" d* \& w3 z6 B2 qresult in extensive, unnecessary, and expensive
- F/ E6 \9 m" |/ H( Winvestigation. The primary care physician should be) t; y; P2 t. d. O9 W+ c
aware of this fact, because most of these children: m# P( S/ d) l4 {4 L
may initially present in their practice. The Physicians’3 N' b" f2 d7 ^. F8 \3 i- u
Desk Reference and package insert should also put a4 e7 y5 A- R! o' }# f7 X
warning about the virilizing effect on a male or! {: n$ A7 ~5 }
female child who might come in contact with some-
! z6 |9 u3 i3 H. o% L! vone using any of these products.+ X8 ^) U! }* q) H
References
* ~5 q5 G7 k# T: \9 l$ {0 m( s1. Styne DM. The testes: disorder of sexual differentiation7 L$ f9 E) p& ^$ C m
and puberty in the male. In: Sperling MA, ed. Pediatric
6 c2 [0 b/ f1 ?8 PEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;+ h* v1 h# S) D
2002: 565-628.
" F' u" T) z. O2 m2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 J! r5 }, y/ }puberty in children with tumours of the suprasellar pineal |
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