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Sexual Precocity in a 16-Month-Old
$ B( m: i% M+ i4 R. c; UBoy Induced by Indirect Topical$ `4 B- a5 d6 O& j4 v) t( P
Exposure to Testosterone) d' ?& }' b; i/ X" M6 J
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 g' Y/ Z, s, m8 [- {; j! Qand Kenneth R. Rettig, MD1
$ n$ X' Q: m, y4 s- L$ hClinical Pediatrics, z) p6 o0 C b7 a) H5 q2 s
Volume 46 Number 6
# }' @0 [+ o2 ^& Q& j7 o0 aJuly 2007 540-5434 T+ u/ j: W& t4 [+ V' f
© 2007 Sage Publications
2 d! q7 Y* D2 ?) _10.1177/0009922806296651
7 x$ f5 C$ W, |5 q B1 F' ahttp://clp.sagepub.com; S% `- I/ V& V' n! ^& R
hosted at% y6 u! t5 m+ \+ l1 n
http://online.sagepub.com s) j- p! S1 M& O0 @% v
Precocious puberty in boys, central or peripheral,
. A" B4 ^+ `/ G+ n ?' iis a significant concern for physicians. Central" D# t; x- k9 ?0 P# M2 k0 ?# ~: G; a
precocious puberty (CPP), which is mediated
9 k" }7 } q& j" V7 ]5 ythrough the hypothalamic pituitary gonadal axis, has0 Y: C( x6 x+ p% t( D' n* N9 G5 O! i
a higher incidence of organic central nervous system
' F9 z' ]6 {8 {' P( Q6 A7 K8 G4 p( Ulesions in boys.1,2 Virilization in boys, as manifested
" ~1 N! Z; y, E: \1 k+ o0 @by enlargement of the penis, development of pubic' j$ ~! y* R Z4 i
hair, and facial acne without enlargement of testi-7 D% O& m- H. f, ~/ d, s0 V, m. C$ {7 K
cles, suggests peripheral or pseudopuberty.1-3 We
1 ~# o: j3 _6 y. j6 hreport a 16-month-old boy who presented with the& Z/ l1 ?; y C7 A; i( [( m
enlargement of the phallus and pubic hair develop-1 A' B! v! }; l% t. n0 ]
ment without testicular enlargement, which was due7 F2 Y o! f+ `6 i- q# ?
to the unintentional exposure to androgen gel used by. u' F1 l3 w4 f$ V$ @1 f/ a2 V! s
the father. The family initially concealed this infor-
/ e; l- J+ `1 Emation, resulting in an extensive work-up for this
" ~% C% V( m) v( ]3 rchild. Given the widespread and easy availability of7 z" v* X/ b6 S7 n: @- s& X7 ?% h
testosterone gel and cream, we believe this is proba-3 `+ F" J0 a; w0 m {0 O+ G
bly more common than the rare case report in the# U4 |& p# z. X1 H+ `% W/ s
literature.4
, T& \6 Q9 v4 s4 cPatient Report
; h4 L+ ?* B1 dA 16-month-old white child was referred to the
+ X# B2 f' Y9 y- z% oendocrine clinic by his pediatrician with the concern
7 b" p: j/ w8 b1 wof early sexual development. His mother noticed
- F6 ]1 M8 E# Z. f! d/ E$ \; @light colored pubic hair development when he was* w" m2 G% C) z0 `; {: Y
From the 1Division of Pediatric Endocrinology, 2University of
Q. E3 y! O: w: W& FSouth Alabama Medical Center, Mobile, Alabama.
, v0 X9 [( A4 I& ^Address correspondence to: Samar K. Bhowmick, MD, FACE,1 h3 q& y1 S. x& N4 @1 V9 j
Professor of Pediatrics, University of South Alabama, College of
7 {, ~( ?& R0 z0 l! g) FMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;0 w( i. _% T3 |( l6 O+ i
e-mail: [email protected]." C) [/ C6 O! x! N, Q2 N1 q2 K
about 6 to 7 months old, which progressively became/ L- E, Q! V. A a0 g8 `" P
darker. She was also concerned about the enlarge-
5 |/ I: b$ ~9 a# sment of his penis and frequent erections. The child2 G% T3 `% c5 P4 b3 b& z
was the product of a full-term normal delivery, with+ E. p* w% n8 j$ E4 R0 d# j
a birth weight of 7 lb 14 oz, and birth length of
& ^ d0 w. z/ T+ w- A20 inches. He was breast-fed throughout the first year
- o. V; D/ s7 tof life and was still receiving breast milk along with1 s+ i% Y g$ a* M
solid food. He had no hospitalizations or surgery,
- x4 ^3 _ s- o6 Band his psychosocial and psychomotor development
' S7 |9 a1 k1 @# \( ^was age appropriate.
) f! O0 K, U. ?% Y# QThe family history was remarkable for the father,
+ V2 j% L/ G6 T8 [' c* twho was diagnosed with hypothyroidism at age 16,. ]/ J3 X, r) ?. \
which was treated with thyroxine. The father’s
# I# ~% Z7 E; X& ]# s( m8 Y4 ?height was 6 feet, and he went through a somewhat- k. u% s5 ?+ ?" a. ?; T$ O
early puberty and had stopped growing by age 14.
( o% N, u5 l2 H* W. I5 cThe father denied taking any other medication. The
3 K7 F" Z, J O. Mchild’s mother was in good health. Her menarche
7 F# I! W" o! K \. q+ M8 T$ r5 p5 Gwas at 11 years of age, and her height was at 5 feet
+ z9 z5 t. x& Z" Z* F" ?' L5 inches. There was no other family history of pre-
$ c/ ]7 g, P" icocious sexual development in the first-degree rela-
- ~8 q4 J8 \- F9 U7 {' t8 ]tives. There were no siblings., t+ A$ E' y' ~9 w
Physical Examination5 U; f2 H2 V0 H8 M
The physical examination revealed a very active,8 b# h* W- F, e" y0 J
playful, and healthy boy. The vital signs documented' `1 B4 |+ y9 P' t
a blood pressure of 85/50 mm Hg, his length was
- \7 L9 h' y, c90 cm (>97th percentile), and his weight was 14.4 kg
* \2 |( G N# N(also >97th percentile). The observed yearly growth- W& Q1 R+ Y+ ~& m6 u# n
velocity was 30 cm (12 inches). The examination of1 F3 y4 ]4 N3 x3 n4 z' R
the neck revealed no thyroid enlargement.0 G' ?5 r& N. R( ^: ^: s$ b, S
The genitourinary examination was remarkable for
4 _ m; @+ U0 k! V8 nenlargement of the penis, with a stretched length of2 Z/ M8 r/ ]8 ?- t1 p2 s
8 cm and a width of 2 cm. The glans penis was very well
% _1 z# F% j7 G4 e9 }' H1 S4 u [1 T' z. xdeveloped. The pubic hair was Tanner II, mostly around
) U4 g& `. P8 v* W5 X540
% x1 ?5 O" j7 F# B! kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" \' s! A- v: q* V$ Z
the base of the phallus and was dark and curled. The3 X7 G! G F+ E- l
testicular volume was prepubertal at 2 mL each.4 g4 Y' n# i" v, N/ ]' R1 R
The skin was moist and smooth and somewhat
- w. e' v9 f$ D5 X- R! d% A: uoily. No axillary hair was noted. There were no
( F# [; m" ?+ u' habnormal skin pigmentations or café-au-lait spots.
% ~& P, x* P$ J0 E# H, [5 GNeurologic evaluation showed deep tendon reflex 2+6 X1 l+ \) K- ?
bilateral and symmetrical. There was no suggestion9 }0 O) f r! h; O
of papilledema.
( @5 b7 \' d% X( x$ |* ~/ sLaboratory Evaluation
, Z4 E6 T y/ {, M5 r; J& FThe bone age was consistent with 28 months by
4 F9 U* {2 N1 w, ?/ L! A3 ]3 O: Busing the standard of Greulich and Pyle at a chrono-
8 B8 G( L1 f6 i" Z) hlogic age of 16 months (advanced).5 Chromosomal/ l. E, n6 U! C5 `
karyotype was 46XY. The thyroid function test1 Z% Q q/ Y* h3 Y' ~. _" A
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ }/ [ t& X# M6 Tlating hormone level was 1.3 µIU/mL (both normal).; N- ^7 m) Q- p9 V& p
The concentrations of serum electrolytes, blood5 d; t4 E* Z4 J& d9 V V$ g! V# }
urea nitrogen, creatinine, and calcium all were5 `8 G; J0 w/ g
within normal range for his age. The concentration
! F/ Y+ c& ^8 [4 vof serum 17-hydroxyprogesterone was 16 ng/dL
4 ~7 C; y3 U7 h! `, I) w+ H(normal, 3 to 90 ng/dL), androstenedione was 20' j8 I: x8 F$ G7 a- E) {
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; A/ z9 }$ h0 | r3 E; Lterone was 38 ng/dL (normal, 50 to 760 ng/dL),$ A G; X) U! k8 C6 E
desoxycorticosterone was 4.3 ng/dL (normal, 7 to# ?; v1 P, e! r; C4 Q% D8 E
49ng/dL), 11-desoxycortisol (specific compound S)
0 W2 j3 a6 s- Z+ W/ m8 @9 Bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% n/ P# x6 I7 etisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total- [; c) f. z4 L) k+ [. T& n( a O
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! ^5 u, o5 \( Z* ~# B6 C6 b) _7 ?and β-human chorionic gonadotropin was less than) C$ p3 k) e( Y" b1 D- j
5 mIU/mL (normal <5 mIU/mL). Serum follicular+ M6 ?* N* i7 @; q
stimulating hormone and leuteinizing hormone. n) q9 E4 v L7 t4 {
concentrations were less than 0.05 mIU/mL
& J; \8 D+ f4 P(prepubertal).
' S8 S9 y( X. w( Z1 I1 {. dThe parents were notified about the laboratory, W' ?+ ~5 q9 f5 ^
results and were informed that all of the tests were; z! Z! I2 }+ _/ f2 W$ N5 S" v
normal except the testosterone level was high. The' q8 e7 h: s! H |( [* ]
follow-up visit was arranged within a few weeks to5 K" K8 S; P+ `) c8 D; _1 A
obtain testicular and abdominal sonograms; how-
7 Z1 T* J7 V" pever, the family did not return for 4 months.
6 P3 g; I0 I1 ~# C+ K( r9 LPhysical examination at this time revealed that the8 E1 R. i& Q) F9 W
child had grown 2.5 cm in 4 months and had gained
+ }9 M" d: {- r) r7 L2 kg of weight. Physical examination remained
& m- e) u, }8 Y* junchanged. Surprisingly, the pubic hair almost com-
( y! V; h6 V- T. Jpletely disappeared except for a few vellous hairs at1 j( }) i4 K2 a) P+ K6 P. c8 p
the base of the phallus. Testicular volume was still 2 f- {; a5 ]! ?4 u
mL, and the size of the penis remained unchanged.! z) c/ N3 U. a% L
The mother also said that the boy was no longer hav-$ v( W# C$ \2 V; ]. {7 O1 y
ing frequent erections.
& M/ R9 x3 k) T( z4 tBoth parents were again questioned about use of
2 f' ]: j) }: q1 Lany ointment/creams that they may have applied to( Z* N/ k* L4 f, B, ]
the child’s skin. This time the father admitted the1 A1 z/ z3 D5 o5 y
Topical Testosterone Exposure / Bhowmick et al 5417 v3 r8 g& V. x! E; k/ I, G
use of testosterone gel twice daily that he was apply-/ U) ?. N% r7 {5 j) e! [: w# l
ing over his own shoulders, chest, and back area for
) ]1 c2 f4 B3 ]a year. The father also revealed he was embarrassed
5 f# X$ G t6 ato disclose that he was using a testosterone gel pre-
' m" Z! ^+ u$ L. T) ]# L+ }( Lscribed by his family physician for decreased libido3 E0 b4 d* }2 l4 e5 V
secondary to depression.4 t8 V$ ^( X e5 z5 O
The child slept in the same bed with parents.
! J- Q1 L( v+ @3 p* Y$ s- c' [: ^The father would hug the baby and hold him on his; N7 H5 w1 e% T
chest for a considerable period of time, causing sig-
, V$ t' E7 g2 {1 y$ C bnificant bare skin contact between baby and father.
6 o+ j- x, [% a, f4 WThe father also admitted that after the phone call,0 ^3 [# C, A& ^! r( K( ~" I
when he learned the testosterone level in the baby4 [# \: f( j% n0 R& T( Z9 \
was high, he then read the product information d/ l1 g6 N8 ~* g! Y, `3 p
packet and concluded that it was most likely the rea-
$ g, x( R+ m9 l8 G( v- ^son for the child’s virilization. At that time, they
0 I3 q5 q$ w6 Pdecided to put the baby in a separate bed, and the
( k5 y+ p+ z% v# o6 a; E8 }; R& [father was not hugging him with bare skin and had
* A; K; S8 V9 d) w9 H2 }8 sbeen using protective clothing. A repeat testosterone
0 P/ e7 w) L# i6 Ktest was ordered, but the family did not go to the! ?9 o& C2 k8 q- H- z; [# @. E+ |
laboratory to obtain the test.* f1 M1 h4 Y: r
Discussion
% j7 T4 ^! K7 ^* @: n8 u0 s, v; XPrecocious puberty in boys is defined as secondary
. z" Z! T. p' k& Y* Usexual development before 9 years of age.1,4
: A5 s- M( P) E gPrecocious puberty is termed as central (true) when1 c5 K$ ^* I+ }
it is caused by the premature activation of hypo-$ p/ y7 O2 R5 C( b5 @, e
thalamic pituitary gonadal axis. CPP is more com-
6 Y2 U/ a% v8 b& P: P, C4 [ v Omon in girls than in boys.1,3 Most boys with CPP
. c3 y x1 t/ umay have a central nervous system lesion that is
, \* q I+ j/ Tresponsible for the early activation of the hypothal-, a U0 e! A: S2 D6 r% `
amic pituitary gonadal axis.1-3 Thus, greater empha-$ I7 z: c2 t2 Z1 W ]
sis has been given to neuroradiologic imaging in/ l6 W% L3 I2 t3 d
boys with precocious puberty. In addition to viril-# y% j5 _# [& i# |
ization, the clinical hallmark of CPP is the symmet-. `! \- }6 ?$ c+ _
rical testicular growth secondary to stimulation by
3 Z5 H& y; d. Q' [0 jgonadotropins.1,3; g& K8 |8 P: d$ Z
Gonadotropin-independent peripheral preco-- b1 W, ~3 I. M" Y0 H
cious puberty in boys also results from inappropriate `( U) c7 J+ u6 x; e9 ]
androgenic stimulation from either endogenous or& f6 b- z" X5 m$ R
exogenous sources, nonpituitary gonadotropin stim-# p% Y4 s$ @, u! X6 k
ulation, and rare activating mutations.3 Virilizing
6 |; v/ z( O6 f! |3 Fcongenital adrenal hyperplasia producing excessive% F) T5 o( H4 i
adrenal androgens is a common cause of precocious8 D6 L7 Q+ U1 d E* C8 w( H; v
puberty in boys.3,46 n* o( O2 a. \' V2 t- N1 _ a* a
The most common form of congenital adrenal
- k& j7 L( q. f+ Y1 j% M& v! }hyperplasia is the 21-hydroxylase enzyme deficiency.( r/ P& ]1 L, C" B& H; }7 Z
The 11-β hydroxylase deficiency may also result in
5 y _, a; l1 \, k9 U: W' S( S2 u9 bexcessive adrenal androgen production, and rarely,
, U( V' S) a \$ Lan adrenal tumor may also cause adrenal androgen) z4 f! u. F* P- W2 R
excess.1,3! W5 G0 v# o, X0 s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 Z% e( d8 `4 g0 g, f542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& W( q- o. Y* o" l
A unique entity of male-limited gonadotropin-! p8 _ O1 T6 w
independent precocious puberty, which is also known
& q* ^, a6 E2 [# ]2 H# b% vas testotoxicosis, may cause precocious puberty at a) ~7 ~, A) C" _7 d3 X/ e) K: L
very young age. The physical findings in these boys
* s3 n8 e! F6 f- Hwith this disorder are full pubertal development,
2 U: m+ I X5 ]including bilateral testicular growth, similar to boys6 X! t8 |3 b3 T( R( c9 Q( K
with CPP. The gonadotropin levels in this disorder1 l! t* P; p# g! t3 ^0 X4 Y& n
are suppressed to prepubertal levels and do not show a: h, {' J3 \
pubertal response of gonadotropin after gonadotropin-
- F1 Y& G# q0 dreleasing hormone stimulation. This is a sex-linked) l* |6 {( F* I' E9 i
autosomal dominant disorder that affects only. y3 j# {0 O" S$ T9 ]* k$ ~
males; therefore, other male members of the family
i, _! F0 T; @: g) Pmay have similar precocious puberty.3- G% y0 _, o; z! l" f6 I
In our patient, physical examination was incon-. v9 o0 `! n. h' z1 e7 c1 c5 d+ y1 [0 D
sistent with true precocious puberty since his testi-
& @: [; ~ m% J: t* Zcles were prepubertal in size. However, testotoxicosis- H( a) U* H6 ~2 h
was in the differential diagnosis because his father3 t+ s/ X1 M. z* U/ T
started puberty somewhat early, and occasionally,% M I3 o) N* W+ D
testicular enlargement is not that evident in the
% G1 c1 [- `& ?3 k' ibeginning of this process.1 In the absence of a neg-- E# ?2 o7 p7 r+ D6 q$ e$ I
ative initial history of androgen exposure, our
: Q& f E/ t/ P; G |biggest concern was virilizing adrenal hyperplasia,2 v( Y8 F1 y" |5 a( R) c
either 21-hydroxylase deficiency or 11-β hydroxylase3 R5 j4 Y& D6 A% y' W/ i* O
deficiency. Those diagnoses were excluded by find-3 f. s* I. R2 l$ x# R, Q
ing the normal level of adrenal steroids.- L3 y9 Q0 u: t$ X& e
The diagnosis of exogenous androgens was strongly" d4 E( |& C/ t4 Q
suspected in a follow-up visit after 4 months because7 V! g7 C* e$ y& E* n
the physical examination revealed the complete disap-" d, O7 Y3 M: w' X0 p
pearance of pubic hair, normal growth velocity, and
: a7 H' S2 q2 e0 W. ndecreased erections. The father admitted using a testos-
$ o4 j { B& _; n+ N" W# J3 kterone gel, which he concealed at first visit. He was
+ [" H7 c, c* H& v# d- ~using it rather frequently, twice a day. The Physicians’
5 v& k0 `0 j2 {& u% g1 UDesk Reference, or package insert of this product, gel or, [1 w& n |8 R2 `+ R
cream, cautions about dermal testosterone transfer to4 @6 y& M, h) I! W
unprotected females through direct skin exposure.! U" @; Q- N q" Z( I9 h
Serum testosterone level was found to be 2 times the. i& E6 J% y: z/ s j3 }" `
baseline value in those females who were exposed to9 e6 F) w8 \ }5 o+ ^
even 15 minutes of direct skin contact with their male1 i5 K. ~1 o: s
partners.6 However, when a shirt covered the applica-
6 I* e T k& E& j$ G- s9 D" Ution site, this testosterone transfer was prevented.( G/ h) H Z# m3 h* M7 f
Our patient’s testosterone level was 60 ng/mL,
) p. X) ~7 y9 m Q4 Twhich was clearly high. Some studies suggest that
6 k5 g, W/ @( p idermal conversion of testosterone to dihydrotestos-, ?: v0 u% O7 k
terone, which is a more potent metabolite, is more
8 r& I7 s5 x6 _" ractive in young children exposed to testosterone& N) {/ j! B$ G/ m! f
exogenously7; however, we did not measure a dihy-) i$ z5 m h. h' t; v/ A
drotestosterone level in our patient. In addition to
. H3 @9 ?% F& c, m0 h/ ^virilization, exposure to exogenous testosterone in" f5 |- |% u- F) b
children results in an increase in growth velocity and
0 y" k! g, M% B2 ?6 `3 f$ m8 o: Tadvanced bone age, as seen in our patient.
/ j8 V' c( n! R9 ^6 W* ]% N a; xThe long-term effect of androgen exposure during
' [& |2 D' @$ ^' l$ B! xearly childhood on pubertal development and final$ P3 |& O" c0 h3 D6 F. G
adult height are not fully known and always remain
. `' @ [, s, [7 U5 ~8 Sa concern. Children treated with short-term testos-7 C9 N- R8 v+ j/ J% p0 \
terone injection or topical androgen may exhibit some* @2 w0 C$ |5 W
acceleration of the skeletal maturation; however, after
. t: T7 R0 z# {* a" q5 Ucessation of treatment, the rate of bone maturation0 p1 h8 c# c# B6 [4 @) t
decelerates and gradually returns to normal.8,9% S( c5 L' `% L0 y
There are conflicting reports and controversy
& y7 K k7 o/ A9 K6 S$ N+ Uover the effect of early androgen exposure on adult
3 O* |# b$ P/ c0 m( kpenile length.10,11 Some reports suggest subnormal) ^2 {& `" Y& N/ J% B
adult penile length, apparently because of downreg-6 l! o4 g# ]; s# {; j
ulation of androgen receptor number.10,12 However,& A0 e0 i2 V5 ?
Sutherland et al13 did not find a correlation between2 L0 Y; @ {7 s& k
childhood testosterone exposure and reduced adult1 q6 P# J; I8 t$ j
penile length in clinical studies.
" A( [9 E0 G& v7 zNonetheless, we do not believe our patient is
( r k6 v3 \' C( r* Fgoing to experience any of the untoward effects from" D" G8 Y& i9 b2 `0 F' k c
testosterone exposure as mentioned earlier because; V/ c$ u2 g2 o! o' v! A, v# l
the exposure was not for a prolonged period of time.( R# ?6 o' u) s" P+ v' R A/ h
Although the bone age was advanced at the time of
( J7 u( g, R) W9 l; jdiagnosis, the child had a normal growth velocity at) E/ R0 Y+ q3 m3 B. k' D
the follow-up visit. It is hoped that his final adult+ |0 n" ]% _/ n- x' j8 y
height will not be affected.
2 |. {3 u4 Q" F! A! t5 S* FAlthough rarely reported, the widespread avail-( P( ^: g7 X3 r& f2 a% ]' O5 x
ability of androgen products in our society may8 ^. l) |2 @$ K0 `1 m c+ D* }
indeed cause more virilization in male or female; r% t( `$ t$ v6 A/ i
children than one would realize. Exposure to andro-7 n* U* ?( f0 F2 E2 l2 [
gen products must be considered and specific ques-" P/ X8 I# ^0 d, a6 h
tioning about the use of a testosterone product or
1 y4 \0 J1 C9 z! \- w6 t% Z0 N Rgel should be asked of the family members during- O! P! X; {+ V6 G9 A. Z
the evaluation of any children who present with vir-
1 h3 l$ P1 d2 h' _% x, Q; Filization or peripheral precocious puberty. The diag-8 r" Y, h P: _0 |
nosis can be established by just a few tests and by
. {+ p3 j& K4 W) K$ a' c6 yappropriate history. The inability to obtain such a
# L% m7 {, N+ K5 }2 thistory, or failure to ask the specific questions, may
1 L# Q& B1 p$ C7 u4 q% a% presult in extensive, unnecessary, and expensive# i; I1 g/ b! A: X- b/ c' h
investigation. The primary care physician should be
$ W( {, @+ x4 l! O# iaware of this fact, because most of these children( P( m2 ]2 J( P/ B, B
may initially present in their practice. The Physicians’
2 I' {' ~$ d/ ?9 cDesk Reference and package insert should also put a9 u5 a) d D7 c/ j; g# Q
warning about the virilizing effect on a male or
' I" m, t2 A, j6 g! X9 wfemale child who might come in contact with some-
! I& l4 k+ F" \6 S3 Cone using any of these products.: \# c$ h% e. W* {6 A0 i6 u
References* Z# z- o6 w( N5 ]
1. Styne DM. The testes: disorder of sexual differentiation9 q N( P5 e4 u, U% J" j) x- x
and puberty in the male. In: Sperling MA, ed. Pediatric* Z1 k5 Y: C/ Y+ r6 d6 c4 c$ K
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 Y5 c+ O. v5 \4 { e
2002: 565-628.
% l& |; q* G3 B7 a3 [2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 k2 ] V$ j, \" t8 m" mpuberty in children with tumours of the suprasellar pineal |
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