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Sexual Precocity in a 16-Month-Old
|+ f9 Q) `* b# v/ ~- UBoy Induced by Indirect Topical D5 s8 p; A1 [
Exposure to Testosterone& ]8 t7 }* p% u9 R" Y( X# a+ ?
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 y0 s# P5 N- O5 ^2 B- D' G# q: ^
and Kenneth R. Rettig, MD13 g8 {! n+ s& m" M
Clinical Pediatrics8 [5 b: A$ Y3 x8 I. u& A- }
Volume 46 Number 6
& {1 Q% w n! sJuly 2007 540-543
" q3 `7 Q& s E4 X _© 2007 Sage Publications
( d/ k+ @# N- {, l10.1177/0009922806296651) c. W$ L9 k5 \9 L8 G5 z0 ~3 ?
http://clp.sagepub.com' O, z4 f- w) c4 Q
hosted at
% \2 s" H) e$ Khttp://online.sagepub.com' ~" s% o: Z2 R+ `
Precocious puberty in boys, central or peripheral,1 `0 v/ Y9 w; i5 O
is a significant concern for physicians. Central8 o6 _/ x+ F. T
precocious puberty (CPP), which is mediated3 l! l" D8 M# Y) s" E
through the hypothalamic pituitary gonadal axis, has
7 s% m6 z( w7 d* L2 g) ia higher incidence of organic central nervous system5 h) x( P' ]7 K: T% }
lesions in boys.1,2 Virilization in boys, as manifested+ M4 ?; u' \) Z
by enlargement of the penis, development of pubic2 y8 z- ^1 D" q% V0 y8 U9 `$ t) g
hair, and facial acne without enlargement of testi-
: ?0 o8 @' V# N: _7 \cles, suggests peripheral or pseudopuberty.1-3 We
' R% ?; a( X: U$ Dreport a 16-month-old boy who presented with the
$ J0 X6 a: a, F) E9 Q2 ^enlargement of the phallus and pubic hair develop-
, n& k5 @. G8 J2 J( X! w6 ^ment without testicular enlargement, which was due; G. i. k* M. Q* Z" G
to the unintentional exposure to androgen gel used by
: Q2 x# B# l5 u3 a/ b9 `8 Cthe father. The family initially concealed this infor-
- A, T0 L, r7 e" K7 Zmation, resulting in an extensive work-up for this. S+ E$ W" a+ |* _# W, \+ M/ P0 n
child. Given the widespread and easy availability of
* s# x3 C/ w U" W2 v( o/ k6 ktestosterone gel and cream, we believe this is proba-9 Z9 N5 q8 u- D- z( ^
bly more common than the rare case report in the& e. R, ^- j4 @ U
literature.46 T" b4 t; ^% y( T& G+ G3 u
Patient Report
4 f! {( C8 H1 R6 J4 N; W. }A 16-month-old white child was referred to the7 ~9 d+ |5 e5 N2 N5 d
endocrine clinic by his pediatrician with the concern$ e8 t. \/ A2 V. I. O' E) @! V
of early sexual development. His mother noticed. g5 H7 G( `7 h
light colored pubic hair development when he was
3 Z, D1 ^2 H2 d8 _9 a/ `From the 1Division of Pediatric Endocrinology, 2University of
- e: T" j. U) n; m( mSouth Alabama Medical Center, Mobile, Alabama.' _7 H+ Q [. K! O" N$ B3 n% J
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& S: I; o0 n8 n9 ?% d0 X8 WProfessor of Pediatrics, University of South Alabama, College of- Z4 U. }" H, m# w G
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;8 n" t( a& Q* m9 \5 b d# E. g' x
e-mail: [email protected].1 A% ~, a0 V3 n- b
about 6 to 7 months old, which progressively became$ T4 q8 v1 o4 b T- I$ l
darker. She was also concerned about the enlarge-7 m. N% d7 U J- a5 l9 A
ment of his penis and frequent erections. The child
8 i9 y' B* m2 A5 Vwas the product of a full-term normal delivery, with
, Q* }& a! ^3 D- L# ba birth weight of 7 lb 14 oz, and birth length of' z/ R& x! J* d2 p8 r% D
20 inches. He was breast-fed throughout the first year+ Q' ]6 q, w, B& S" n
of life and was still receiving breast milk along with
6 u4 H/ q7 \$ u* W, }solid food. He had no hospitalizations or surgery,& F; \3 W4 ~: N7 `; U. h
and his psychosocial and psychomotor development# ^/ A" q+ m. g, m
was age appropriate.
+ G# u% s# c g) XThe family history was remarkable for the father,
$ M Z' i# s6 W, \who was diagnosed with hypothyroidism at age 16,- u3 f7 y, R$ _
which was treated with thyroxine. The father’s" U M, e9 \9 L7 h/ Y0 q
height was 6 feet, and he went through a somewhat
; G( E; l1 v) T. |) hearly puberty and had stopped growing by age 14.
) z$ i6 |: c; E& eThe father denied taking any other medication. The
; P1 p6 L; _# Z- d) uchild’s mother was in good health. Her menarche" W3 j f( q+ S
was at 11 years of age, and her height was at 5 feet
; g5 J- \& l/ R/ n- ?1 z# q& [5 inches. There was no other family history of pre-
5 N- h) i3 s7 @cocious sexual development in the first-degree rela-- s1 _: a4 A0 B, o# S: Y0 @
tives. There were no siblings.
# M1 o! }4 t# z; jPhysical Examination3 h; O7 F1 j! N
The physical examination revealed a very active,6 H4 z+ a; D& I7 s3 V8 m$ S& j
playful, and healthy boy. The vital signs documented( }: b% R$ Y4 R5 |7 H
a blood pressure of 85/50 mm Hg, his length was
+ Y% G1 ?2 ~! w( V! a' y" ~) |8 A90 cm (>97th percentile), and his weight was 14.4 kg
c( A4 d) \+ ~, j) g(also >97th percentile). The observed yearly growth
, o/ v% k3 a1 d+ H, T7 Jvelocity was 30 cm (12 inches). The examination of
. U; l7 x7 {, {! r+ kthe neck revealed no thyroid enlargement.
, f( A2 f& I5 F, U7 ~* cThe genitourinary examination was remarkable for
W5 w- r r/ Z, k: t9 G1 Z5 qenlargement of the penis, with a stretched length of
8 F" W; L! x- S" n0 J+ y8 cm and a width of 2 cm. The glans penis was very well# [- a1 [' G. s; H/ U5 S/ g
developed. The pubic hair was Tanner II, mostly around7 e1 ~1 }7 |' S
5409 k6 Y# G0 u6 F8 t# G
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 E! G! q5 ~- n% b
the base of the phallus and was dark and curled. The
# |( _4 `+ r& qtesticular volume was prepubertal at 2 mL each.
: U' G: W | m9 IThe skin was moist and smooth and somewhat
# ~, { I c& Koily. No axillary hair was noted. There were no
% s1 q5 a4 c' }0 u$ b$ o3 M7 B4 _# cabnormal skin pigmentations or café-au-lait spots.
, ^% I+ b+ v6 R/ H: z9 _7 |6 Q' @Neurologic evaluation showed deep tendon reflex 2+. q' x% ~/ m1 F/ {0 C- z
bilateral and symmetrical. There was no suggestion
2 d" a a9 d9 z3 E7 Sof papilledema.
( {+ @# L, O( U" M1 qLaboratory Evaluation
) N' K' I4 _' cThe bone age was consistent with 28 months by
& i9 M* @9 A9 s6 cusing the standard of Greulich and Pyle at a chrono- w" t: s- X+ |5 _0 k7 J2 }
logic age of 16 months (advanced).5 Chromosomal
' {7 \$ A( W1 W3 ]karyotype was 46XY. The thyroid function test
% L' F( b7 [7 i8 c- `1 Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-" k3 u3 P3 O# s. I. o
lating hormone level was 1.3 µIU/mL (both normal).
# ?/ D9 P0 o4 S: Z. gThe concentrations of serum electrolytes, blood' @- }% a: C5 v. p1 w& w S, ~
urea nitrogen, creatinine, and calcium all were) o# m# k6 _7 k2 r
within normal range for his age. The concentration j) V$ P S" T; \: _& X9 P3 `
of serum 17-hydroxyprogesterone was 16 ng/dL& V* d9 ~' N/ X
(normal, 3 to 90 ng/dL), androstenedione was 20
; O1 m8 L# [7 z4 S8 mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ }; Z0 \( A4 m- J6 s: m) T
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
% {; ]9 z& G9 udesoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 V7 D0 d/ v, z l, l' x5 H X49ng/dL), 11-desoxycortisol (specific compound S)
4 x" ]* S7 m2 W. c- ~was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
" Y& G0 B) M9 `# Wtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total8 ]4 I9 o& S V& y8 e
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),0 p8 V' a7 H3 t( N
and β-human chorionic gonadotropin was less than2 R, l# M* o O: o- W" W) k i
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 N. r _: y- }: X8 bstimulating hormone and leuteinizing hormone7 i( ~* x, {* ^, T$ U
concentrations were less than 0.05 mIU/mL
, X3 H3 T4 ]8 `9 k6 F) ]+ a(prepubertal).
) z+ o/ f- l9 i1 kThe parents were notified about the laboratory
6 F# `7 J6 y8 eresults and were informed that all of the tests were% \4 a# w/ S6 k# _
normal except the testosterone level was high. The6 Z9 ^7 m2 i2 c
follow-up visit was arranged within a few weeks to
) j& S) ]4 L$ a3 l/ `( S" }& i1 mobtain testicular and abdominal sonograms; how-
- c5 @! o) W5 \, x a0 S& vever, the family did not return for 4 months.4 _0 O% d% j! o0 [
Physical examination at this time revealed that the) L: ]% t; W& c. a' v
child had grown 2.5 cm in 4 months and had gained
: c% T7 c7 p& L \2 kg of weight. Physical examination remained
2 }2 A' ]0 I" Q& p3 t/ [unchanged. Surprisingly, the pubic hair almost com-
8 k) z- M: p: e) E. Q8 {! Spletely disappeared except for a few vellous hairs at
& C8 E# S! Z) G9 @, [& S7 Tthe base of the phallus. Testicular volume was still 2
+ X# l. _1 x g' c. ZmL, and the size of the penis remained unchanged.* `; N! [& `* t9 j9 G* G
The mother also said that the boy was no longer hav- r' Y1 x0 M: M; Y
ing frequent erections.
, ^- U* J0 Y. L( LBoth parents were again questioned about use of4 p% W3 J0 p \3 Y) ~: p
any ointment/creams that they may have applied to
& n l+ U7 {8 |- l+ Q; ?- ethe child’s skin. This time the father admitted the" Y/ r; p+ w# X' P
Topical Testosterone Exposure / Bhowmick et al 541
( `1 t) s: @- @- P7 k: Q) Q3 Wuse of testosterone gel twice daily that he was apply-
2 u+ ^( K6 l, F2 H Y- oing over his own shoulders, chest, and back area for
- C+ b2 {- a+ y) z* A0 F6 v& }a year. The father also revealed he was embarrassed
j) D' ?# z" Y# ], R+ D) H7 S' @# ito disclose that he was using a testosterone gel pre-, e9 C- g- ~7 i
scribed by his family physician for decreased libido
$ ~4 }# p" S" D( H. gsecondary to depression.
+ |& B8 l: V( f/ PThe child slept in the same bed with parents./ I4 y. _0 e7 o2 `7 K
The father would hug the baby and hold him on his% w1 r9 `4 ]5 b1 @. o/ O
chest for a considerable period of time, causing sig-& \( k- ^ r+ B
nificant bare skin contact between baby and father.
, d2 E# B2 r9 `- P7 o- SThe father also admitted that after the phone call,/ d) Q1 T5 {- B' K: m. K! ~( Y
when he learned the testosterone level in the baby/ D' Y5 d0 R1 b$ B( }; e5 P* x7 b
was high, he then read the product information
7 z5 r: C$ x9 B1 Z; z8 w% opacket and concluded that it was most likely the rea-
2 C! _ Y* F9 d3 a6 yson for the child’s virilization. At that time, they% Q6 @+ O m) P
decided to put the baby in a separate bed, and the" ?1 ?8 n' l7 P2 w$ z! [" t
father was not hugging him with bare skin and had; W8 }3 M/ T( ?/ n: {" v) f
been using protective clothing. A repeat testosterone7 t& E8 G. G) d8 Q
test was ordered, but the family did not go to the
$ K; S0 \8 p( glaboratory to obtain the test.
+ ^& |8 P9 L! b- Y6 P2 _* F% d; EDiscussion+ I/ F, T5 R3 ^% i) J+ l- P) X
Precocious puberty in boys is defined as secondary# U, }# ^% T/ H
sexual development before 9 years of age.1,4- a: t4 o: v" }" M: X, r7 U5 C
Precocious puberty is termed as central (true) when) L, T5 a5 ~' s; F. J" z* \
it is caused by the premature activation of hypo-
( i0 X s& A0 q. O0 Q+ P3 |' Xthalamic pituitary gonadal axis. CPP is more com-
1 _' S; S. e& p) Fmon in girls than in boys.1,3 Most boys with CPP+ t7 _- v# [6 T6 z/ }& B
may have a central nervous system lesion that is
- A) K% ?1 F) E3 Sresponsible for the early activation of the hypothal- Y$ Q# a, Y* [6 ?+ c% f
amic pituitary gonadal axis.1-3 Thus, greater empha-) t' [+ R" ]0 ]3 `2 V5 g
sis has been given to neuroradiologic imaging in
* A2 {$ s6 O9 v7 Wboys with precocious puberty. In addition to viril-$ D/ ~$ O, M' ?
ization, the clinical hallmark of CPP is the symmet-
' D3 ?% i& b7 }2 Drical testicular growth secondary to stimulation by
1 O- d; w, P& o; I' w, j8 l vgonadotropins.1,3
$ z% m5 l+ R7 l* C, VGonadotropin-independent peripheral preco-9 }$ a- D9 K' D: H/ |
cious puberty in boys also results from inappropriate
% U" p0 a# H1 f* z3 G4 X8 fandrogenic stimulation from either endogenous or
4 S5 L; r' t/ Q' dexogenous sources, nonpituitary gonadotropin stim-7 `; H$ [/ j ?6 {* i( {/ P
ulation, and rare activating mutations.3 Virilizing
2 M( ]2 Q" I' S, hcongenital adrenal hyperplasia producing excessive! N8 }9 [8 i x3 @3 h6 T2 J
adrenal androgens is a common cause of precocious1 W+ }6 @& k- M9 }* N- Y
puberty in boys.3,4. v! E. f, U+ X3 U; G
The most common form of congenital adrenal
) B# a$ z9 g) r3 ~0 G$ dhyperplasia is the 21-hydroxylase enzyme deficiency.4 _3 N# o3 Z& S9 J
The 11-β hydroxylase deficiency may also result in8 Z" h8 @9 N5 q. S5 ?% Q! L- _( r
excessive adrenal androgen production, and rarely,
9 g) ^- Q0 ^/ ~, Q) kan adrenal tumor may also cause adrenal androgen+ E( v9 X n$ l0 p/ w; k
excess.1,3
% I0 M6 N Q9 {& H& Z& {at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' H/ t3 n; c3 x) S542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 }' ? e8 A# S' d+ @% KA unique entity of male-limited gonadotropin-
4 @% y0 O$ N) oindependent precocious puberty, which is also known! B/ ]6 Y5 {0 { N. U0 q
as testotoxicosis, may cause precocious puberty at a, t, b( @6 Z K# N" L
very young age. The physical findings in these boys% o; F Z5 Z& z' j
with this disorder are full pubertal development,2 o) z& s9 h2 C' S; R" R( ]9 l0 N: T
including bilateral testicular growth, similar to boys
7 W# |7 `: ^$ v9 @+ J+ Uwith CPP. The gonadotropin levels in this disorder
0 x2 O9 ^" |+ O) C6 j) f9 `are suppressed to prepubertal levels and do not show i2 X5 [+ T9 B( c% X6 [% n
pubertal response of gonadotropin after gonadotropin-
+ z6 C! Z4 ~- W* s1 }: @# V+ V B% \releasing hormone stimulation. This is a sex-linked% o+ J& M7 h, V7 e* Y- ?
autosomal dominant disorder that affects only) L3 M* W4 Z7 h% J& K* f+ @
males; therefore, other male members of the family
2 {& b. G: e6 Z k! ?4 p$ b# Emay have similar precocious puberty.3$ ]( G; D+ f% p/ M' d) X
In our patient, physical examination was incon-+ W2 ~+ z2 K& q- t$ E, P$ n* P0 D
sistent with true precocious puberty since his testi-
- ^: p u; d; m* l% Q0 x; icles were prepubertal in size. However, testotoxicosis6 I" v. I$ k2 Q+ P
was in the differential diagnosis because his father
+ B# P( z& _3 ~1 g, C# y: Gstarted puberty somewhat early, and occasionally,2 I4 W" K# i1 k/ Q5 K" |! ~+ G
testicular enlargement is not that evident in the3 n- c/ Z7 h+ ^# R" } y# x
beginning of this process.1 In the absence of a neg-9 x8 ~, \- o3 |4 n& A1 R0 N2 r
ative initial history of androgen exposure, our; S& c j6 N1 C* X$ u( N( B
biggest concern was virilizing adrenal hyperplasia,& W) E) L- G7 [& ~* c T4 u: s3 H8 b1 h
either 21-hydroxylase deficiency or 11-β hydroxylase
. q/ ^0 j. i3 I% w- o2 c" h7 q1 {deficiency. Those diagnoses were excluded by find-1 ]: }; M. O9 H
ing the normal level of adrenal steroids.
0 `* ?& m# e1 _8 }$ r6 D; MThe diagnosis of exogenous androgens was strongly
0 ?" P2 M; g8 D$ P$ y6 U4 zsuspected in a follow-up visit after 4 months because
9 e. w2 B; L2 F, _the physical examination revealed the complete disap-
" L9 c3 M; J+ \5 T7 `: l) Jpearance of pubic hair, normal growth velocity, and$ E. ]6 K% Q" {$ n A" z: o# v0 r
decreased erections. The father admitted using a testos-
. J$ _- a; @/ ?4 c) Eterone gel, which he concealed at first visit. He was+ j6 I, c, R1 F! e
using it rather frequently, twice a day. The Physicians’
9 A x0 I, W& w& _Desk Reference, or package insert of this product, gel or5 i1 |7 S1 C$ v! s. b
cream, cautions about dermal testosterone transfer to
6 h; B4 p- { V: G$ A$ Xunprotected females through direct skin exposure." y6 E/ r0 b8 x& K, B, g/ `% \
Serum testosterone level was found to be 2 times the
& u$ ~% e1 w! D. \, ?baseline value in those females who were exposed to
3 ^; S( p6 Q) D9 x0 s& a& qeven 15 minutes of direct skin contact with their male& }. ]5 m' z# ~
partners.6 However, when a shirt covered the applica-
1 ~" F) ]1 K; }% ttion site, this testosterone transfer was prevented.
9 @* A/ M* S8 T5 ]Our patient’s testosterone level was 60 ng/mL,$ x; C! I K# p' e* _! T2 x
which was clearly high. Some studies suggest that, B4 Q! b9 I) S3 ~1 C
dermal conversion of testosterone to dihydrotestos-
; h* R- t6 o: f8 H Z+ b) i9 lterone, which is a more potent metabolite, is more/ o2 e4 ?% J/ v- p8 ?" J6 |
active in young children exposed to testosterone
$ m3 r p3 l3 s7 mexogenously7; however, we did not measure a dihy-) a* H3 V# b. j: |. j
drotestosterone level in our patient. In addition to2 t5 D4 N4 O: B
virilization, exposure to exogenous testosterone in( k7 [3 d/ R* y. l- s( o o6 |
children results in an increase in growth velocity and
& t' O* B- [" b; F: H: T% `advanced bone age, as seen in our patient.
4 N% f2 X6 L9 e# n6 a$ V' N. w- QThe long-term effect of androgen exposure during- o, a9 v/ r* j1 Y \7 C
early childhood on pubertal development and final
9 i7 L. x3 L4 radult height are not fully known and always remain
. A( @* W3 E& S, o5 X/ e' i1 ua concern. Children treated with short-term testos-
# O9 h3 O" h" P# L! w0 _ Iterone injection or topical androgen may exhibit some
4 l% k) q0 E' G8 k' g: Cacceleration of the skeletal maturation; however, after$ V4 _) M* l2 o& a
cessation of treatment, the rate of bone maturation
# c* |" C& w7 mdecelerates and gradually returns to normal.8,9/ V- k) ?3 p: |8 q
There are conflicting reports and controversy. c5 _3 H+ P) m
over the effect of early androgen exposure on adult* G1 A- K" e. U1 C
penile length.10,11 Some reports suggest subnormal
( M0 _- Q3 _" \* b5 H) s/ gadult penile length, apparently because of downreg-8 v, m" `; q' @% [: z. a- L
ulation of androgen receptor number.10,12 However,) c) v% h( V# d) H3 L" s, S) y
Sutherland et al13 did not find a correlation between& f! ~- X0 m3 g% n! `
childhood testosterone exposure and reduced adult+ n( h5 J0 N+ q& L
penile length in clinical studies.
+ `; F% O: G1 g! H$ NNonetheless, we do not believe our patient is
- k; \: m) ]! ]2 l2 b$ ggoing to experience any of the untoward effects from* o+ C6 ?$ q; M: r! h/ f( z
testosterone exposure as mentioned earlier because0 H7 }. ]* S6 ^- g/ o3 }
the exposure was not for a prolonged period of time.8 W! r/ P; Q h0 u9 l
Although the bone age was advanced at the time of/ _. o2 W% A# M1 Y. S0 ?
diagnosis, the child had a normal growth velocity at2 ~: u8 x6 l$ S4 F
the follow-up visit. It is hoped that his final adult& r8 a; |; k* p
height will not be affected.
9 ?2 d* d2 B7 J7 mAlthough rarely reported, the widespread avail-
8 e( [& ]; w1 C5 F8 ^ability of androgen products in our society may
% [$ T4 C5 g8 E+ e! I( tindeed cause more virilization in male or female
/ y# T/ P3 k0 G, S5 W* rchildren than one would realize. Exposure to andro-" n8 Y% \3 K* y F2 ~
gen products must be considered and specific ques-$ l9 c1 }" D1 X" b7 A) G3 y
tioning about the use of a testosterone product or
' O# s: H6 \" m2 @! j1 Y7 P! Y6 Zgel should be asked of the family members during
+ j+ n+ u) ?$ N5 O0 W" uthe evaluation of any children who present with vir-
; E. g# o7 k6 O7 Nilization or peripheral precocious puberty. The diag-
6 D8 e5 G B3 E: o' f; e# qnosis can be established by just a few tests and by+ @8 V% G- T& W4 N3 Q
appropriate history. The inability to obtain such a
- l- N0 j& L/ t5 c- N$ S( @$ yhistory, or failure to ask the specific questions, may0 _- a! Y, s: {& A! k
result in extensive, unnecessary, and expensive+ b; j0 }# N% V" _3 P4 M
investigation. The primary care physician should be
# t/ b0 I1 Y* a1 x3 o) q( daware of this fact, because most of these children
$ q" n' u$ V1 smay initially present in their practice. The Physicians’ d0 N* Z; ]/ O
Desk Reference and package insert should also put a2 N: P P8 V1 |. t
warning about the virilizing effect on a male or( q D: m, G5 O9 D3 D# ]* ?
female child who might come in contact with some-
6 }9 c$ E8 r! H0 |7 M# ~4 Rone using any of these products.
8 j/ L6 r" O: ?) }+ YReferences
% k) U" A7 g" P1. Styne DM. The testes: disorder of sexual differentiation
# P0 s' X/ u* u5 `2 J' v$ wand puberty in the male. In: Sperling MA, ed. Pediatric
1 t2 ]; {* W& J8 P5 XEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 L" k) X1 x2 |+ r, g2002: 565-628.3 [5 v% s+ u" l6 r# r* ^
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: h# l1 M/ [. [$ X) I1 x
puberty in children with tumours of the suprasellar pineal |
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