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Sexual Precocity in a 16-Month-Old. ~ t9 c; S( A/ x
Boy Induced by Indirect Topical
, L* |8 }) S" r) c mExposure to Testosterone3 N5 _$ Q* ]- v- h" R6 g
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! a4 r& }8 z6 R0 g! h1 A. e3 }
and Kenneth R. Rettig, MD17 V, K1 V. C. m. M
Clinical Pediatrics! E4 B, C& N! ?0 a% I
Volume 46 Number 6$ ~; y: r% M( S* J- L) e$ U
July 2007 540-543
- |+ v! l: N( K: _, u& \© 2007 Sage Publications4 k$ z _, y1 V; p* s Y/ J! X
10.1177/0009922806296651, P/ J( X9 q2 r
http://clp.sagepub.com
8 f. ?0 @, X& ^1 {1 _hosted at, T9 }/ a0 Q, V2 O5 y9 P
http://online.sagepub.com+ h5 ^* O* p% T$ p# F5 o
Precocious puberty in boys, central or peripheral,
( s; s U9 O" d% _9 v" |# kis a significant concern for physicians. Central0 w1 W/ Z" P' G# T
precocious puberty (CPP), which is mediated6 Q+ A0 x4 Z8 d7 d. C( T2 Y
through the hypothalamic pituitary gonadal axis, has
8 P. l; G* i e% Q `a higher incidence of organic central nervous system
7 t ^+ n, {1 J# ?$ t- _, o, u, ulesions in boys.1,2 Virilization in boys, as manifested; c& `! w; }* ^4 w
by enlargement of the penis, development of pubic7 L1 p* G; ]/ `% r
hair, and facial acne without enlargement of testi-
; _$ k# q% X9 D. Y: c* P6 Ycles, suggests peripheral or pseudopuberty.1-3 We$ b( B+ @% L8 G( g# Q, U
report a 16-month-old boy who presented with the
& n/ J, J M C/ Z. g! H Lenlargement of the phallus and pubic hair develop-
* F A. f7 p4 m8 j- Bment without testicular enlargement, which was due0 \- z X' E6 H9 L( ^
to the unintentional exposure to androgen gel used by2 [1 \3 j7 j/ q( _' I
the father. The family initially concealed this infor-# N$ {5 @) M- M- `& L3 c7 H
mation, resulting in an extensive work-up for this9 f+ W8 k; d. h& \6 h
child. Given the widespread and easy availability of
1 e; A& e$ z% Ntestosterone gel and cream, we believe this is proba-: Z* N4 U1 s' @5 z; L( @- P
bly more common than the rare case report in the9 [& M) V2 _/ B5 a
literature.4
1 [7 K3 c; m* S4 n0 V2 T, xPatient Report3 T6 Y; {1 x5 g3 R' ~% M
A 16-month-old white child was referred to the
. J* W R( o: [0 R: Qendocrine clinic by his pediatrician with the concern& b; Z8 d( v$ p, N
of early sexual development. His mother noticed
- s( d; ?. R! z2 A- y' Alight colored pubic hair development when he was. f/ W* q& q, @
From the 1Division of Pediatric Endocrinology, 2University of
) D. \1 U& ~5 ] }+ g* TSouth Alabama Medical Center, Mobile, Alabama.) j/ R8 ^; A1 L- u
Address correspondence to: Samar K. Bhowmick, MD, FACE,
% x# O: k# P; v5 wProfessor of Pediatrics, University of South Alabama, College of4 i, H& N" z0 ] @9 H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 t+ E0 ]# {) [5 x
e-mail: [email protected].' i! ?6 D0 K6 |( |; r" Q
about 6 to 7 months old, which progressively became# m( W8 I$ _5 p+ J- w
darker. She was also concerned about the enlarge-7 Z8 r# \6 S4 F: R6 U
ment of his penis and frequent erections. The child
3 s7 a9 W6 F, ?6 c: P7 O+ ^9 nwas the product of a full-term normal delivery, with
4 Y/ `( F; X4 F8 _/ s f" Sa birth weight of 7 lb 14 oz, and birth length of: h4 S) Q- l5 Y) \, u2 s$ I
20 inches. He was breast-fed throughout the first year5 t5 ~7 v" ?& m9 U
of life and was still receiving breast milk along with
8 Q# U: }( f6 W& Bsolid food. He had no hospitalizations or surgery,
) O& {' g9 S% P8 A, A7 M7 dand his psychosocial and psychomotor development
% X/ t+ x& ^/ ewas age appropriate.8 E4 _6 M8 b F! i4 {' g' I+ n* e6 S
The family history was remarkable for the father,5 m* q+ ^: ? l. \. s2 f" y
who was diagnosed with hypothyroidism at age 16,
# D( b; [, P; a1 g( Hwhich was treated with thyroxine. The father’s
: R& |! E6 U5 `3 Fheight was 6 feet, and he went through a somewhat% `' w5 e: l7 y3 k9 C* a
early puberty and had stopped growing by age 14.
4 D4 J8 q, J! k1 [The father denied taking any other medication. The3 j5 G( a& C! X5 u1 o$ ?( q! G
child’s mother was in good health. Her menarche, |# {0 c8 o4 n9 O$ {/ K6 G
was at 11 years of age, and her height was at 5 feet' B) N+ l5 m8 y8 h2 h
5 inches. There was no other family history of pre-
% `8 m3 Z! ]; E) r3 n1 R0 e; `cocious sexual development in the first-degree rela-" E1 Z) A9 R3 S! M
tives. There were no siblings.
+ B% {/ E& ~- w8 t! a: lPhysical Examination- J+ x: ~ h* Q; [; q, ?
The physical examination revealed a very active,
$ A. @' x/ q6 t3 [" E2 G9 J8 wplayful, and healthy boy. The vital signs documented
5 X3 Q7 z7 L q9 T6 _" O/ a pa blood pressure of 85/50 mm Hg, his length was* F7 n$ C8 X" S
90 cm (>97th percentile), and his weight was 14.4 kg
& x3 w* H4 r6 @ t ~, K(also >97th percentile). The observed yearly growth( r ? f1 e v7 u. Y! C
velocity was 30 cm (12 inches). The examination of, L+ Q/ }, O% E6 r! b9 u* P* k. r
the neck revealed no thyroid enlargement.
* D+ v' ~! g: `9 e" jThe genitourinary examination was remarkable for
" C& e# R K, f9 M: senlargement of the penis, with a stretched length of, Q: h) o S- J* M7 Q5 B
8 cm and a width of 2 cm. The glans penis was very well
& a! h4 `+ h* `/ q7 kdeveloped. The pubic hair was Tanner II, mostly around
$ U+ d. \; e, E/ w4 [7 U5405 w- {* T3 q0 x5 t+ D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) h6 G$ D- T0 H+ T% m' |# Rthe base of the phallus and was dark and curled. The- M% Z: u& C. h7 M5 _4 c
testicular volume was prepubertal at 2 mL each.6 F% N9 P' O: K r% H* K/ M9 P
The skin was moist and smooth and somewhat5 B/ I& l4 Z3 P F1 ^$ Y. w
oily. No axillary hair was noted. There were no
S4 p/ u) E2 {) c% r" Habnormal skin pigmentations or café-au-lait spots.+ P, }% V: \, @
Neurologic evaluation showed deep tendon reflex 2+3 s, L' z2 b$ ?
bilateral and symmetrical. There was no suggestion, j+ G% K% q4 A: U( b
of papilledema.
$ z- @6 w6 i1 GLaboratory Evaluation
. J9 u: K+ `# r' A1 kThe bone age was consistent with 28 months by
7 X* O9 o1 ~/ ousing the standard of Greulich and Pyle at a chrono-
* o8 B1 [0 |; L3 Alogic age of 16 months (advanced).5 Chromosomal
! W" _* x! P9 A2 j$ {7 Dkaryotype was 46XY. The thyroid function test0 V" X) F) w, m6 |
showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 \: x+ M( |# Q1 p3 F8 |" X
lating hormone level was 1.3 µIU/mL (both normal).9 l; r0 d$ g3 t% ^
The concentrations of serum electrolytes, blood' h! u8 k) K0 e
urea nitrogen, creatinine, and calcium all were0 g. E& M) P( K% Q2 N4 r8 u
within normal range for his age. The concentration
8 U% `1 V+ j5 ^2 o6 ~8 ^2 t. S1 V7 {5 l* Wof serum 17-hydroxyprogesterone was 16 ng/dL
* u; c6 N$ l2 m8 h(normal, 3 to 90 ng/dL), androstenedione was 20! \& r7 x7 S. l8 `, m
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: A) J* F) b( t
terone was 38 ng/dL (normal, 50 to 760 ng/dL),* B. Z$ G7 s; Q! r3 t
desoxycorticosterone was 4.3 ng/dL (normal, 7 to* @2 ^' U. c3 \# p
49ng/dL), 11-desoxycortisol (specific compound S); p7 |! b* I- ?; U8 v
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: G! x2 {+ j) g' m" v/ s8 }4 e' h
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' ]$ r& X9 G5 _, b8 z
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, ^8 `9 j8 Z: X% \ Rand β-human chorionic gonadotropin was less than
; x h* k0 y- K% N* ?7 J! l5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 T( a% F! `& a5 f4 O9 Qstimulating hormone and leuteinizing hormone# n1 z+ F3 o* K' K. q9 B# q. h
concentrations were less than 0.05 mIU/mL
+ C4 u; ~( d7 n& T7 {(prepubertal).' I' z* x) Z: n
The parents were notified about the laboratory
: g. k8 h, o" z, m: C* @' N. Sresults and were informed that all of the tests were+ B2 ~+ a% S, w
normal except the testosterone level was high. The
) o" z6 I& z8 X$ _6 F0 _& c# `follow-up visit was arranged within a few weeks to
' P" G+ S/ d+ w2 n7 j) k8 Gobtain testicular and abdominal sonograms; how-
2 [8 O. Y! S9 [! a; }4 h. }ever, the family did not return for 4 months.
- h' O3 \, S9 I6 P! p- S- qPhysical examination at this time revealed that the
8 q! z( d9 H7 E8 T8 c7 \child had grown 2.5 cm in 4 months and had gained1 r7 T! Z9 K: C& U6 f
2 kg of weight. Physical examination remained- |- |) x6 d# z& H
unchanged. Surprisingly, the pubic hair almost com-
* d8 p, \) Z' Z. ]2 Apletely disappeared except for a few vellous hairs at
, N, Y4 Q. O5 Y% o, Fthe base of the phallus. Testicular volume was still 2 I6 T8 z3 I& x$ }
mL, and the size of the penis remained unchanged.2 g5 Z- N/ G7 j$ y- C- {$ x
The mother also said that the boy was no longer hav-
6 M7 |3 ?( i+ C) r$ Z1 King frequent erections.9 O; Y$ T, h, h& O5 r
Both parents were again questioned about use of3 s, Y* |* r. ~7 v) r; s* j
any ointment/creams that they may have applied to }1 i) Q4 b& [" t8 I9 W9 L; l
the child’s skin. This time the father admitted the
2 E$ ?/ U7 p/ N" S+ C NTopical Testosterone Exposure / Bhowmick et al 541
4 W/ ?. c% I' `* J/ Muse of testosterone gel twice daily that he was apply-
- C% y! \( \( h& x0 n6 d, Fing over his own shoulders, chest, and back area for
! c k2 m9 u& C7 R3 Y: U( u3 M' i. Ma year. The father also revealed he was embarrassed) v6 x2 s3 S U
to disclose that he was using a testosterone gel pre-
% J) f0 O+ c _) p: n* t4 L4 y3 Xscribed by his family physician for decreased libido
( S( m0 r Q3 \% W2 Qsecondary to depression.: x) R( w+ T: x/ T7 q* M; B- L
The child slept in the same bed with parents.
, {" l: T9 A, W( B/ k3 V3 MThe father would hug the baby and hold him on his
; _2 Q- V" {' [+ ~chest for a considerable period of time, causing sig-- I; b, j+ J: X# h' d3 Y0 u
nificant bare skin contact between baby and father.( j* N( o9 }% U+ U. x7 |
The father also admitted that after the phone call,
( X& }. Y: _2 l0 Y* |" Owhen he learned the testosterone level in the baby4 p: T2 _8 s; y! ~! W* o
was high, he then read the product information, h7 N4 U4 ~0 [- E% t8 C( z3 W
packet and concluded that it was most likely the rea-
; z7 A7 X5 H2 a" `. M( q6 Ason for the child’s virilization. At that time, they6 I8 [6 z& y: M3 }) B" Y
decided to put the baby in a separate bed, and the
! G" C: z2 b" ofather was not hugging him with bare skin and had
3 ]0 I' l3 s1 o, abeen using protective clothing. A repeat testosterone7 ^; ]8 h( [" l; T8 d5 k
test was ordered, but the family did not go to the ^" T2 Z- ~8 ]
laboratory to obtain the test.6 P& C! x4 ? X; i4 @
Discussion
% g; |$ C( M; M: | s4 bPrecocious puberty in boys is defined as secondary
; N2 U X: Z' Q8 a* Fsexual development before 9 years of age.1,4
3 S/ k4 z9 s w% ?1 p pPrecocious puberty is termed as central (true) when
6 \! ~* G3 Q5 tit is caused by the premature activation of hypo-' ^# |# V- s/ p! f1 V
thalamic pituitary gonadal axis. CPP is more com-! ?% {8 P+ M6 F( K
mon in girls than in boys.1,3 Most boys with CPP: Q. `) h% S3 q& }, y' @
may have a central nervous system lesion that is- E8 M, m, o( K; F$ y* Y! G$ \
responsible for the early activation of the hypothal-
7 t {* C/ m7 G7 Qamic pituitary gonadal axis.1-3 Thus, greater empha-
8 |% t, l$ y9 b4 c/ Csis has been given to neuroradiologic imaging in% _/ x; A: g; w7 e7 Y& y0 e* ^
boys with precocious puberty. In addition to viril-, s* b& U0 n* g" m( N
ization, the clinical hallmark of CPP is the symmet-. R& l* z, ~6 }9 I( n
rical testicular growth secondary to stimulation by- _% L) s4 u1 l
gonadotropins.1,3$ x5 n" n( H8 y9 B; Y
Gonadotropin-independent peripheral preco-# A* O2 i( @4 O! E: I
cious puberty in boys also results from inappropriate; Z/ l& u9 Q" V3 g
androgenic stimulation from either endogenous or9 S* b# i" _. I
exogenous sources, nonpituitary gonadotropin stim-
4 R; ^) x9 w& Y/ X' [/ B$ L7 o& julation, and rare activating mutations.3 Virilizing. |7 `) ?# \- C0 f
congenital adrenal hyperplasia producing excessive
6 @- P& {8 F" F1 `adrenal androgens is a common cause of precocious1 e# k; o" {$ r; }+ f& f3 r/ @
puberty in boys.3,4
+ `. C: }) N3 ?; p4 m5 k5 `# PThe most common form of congenital adrenal
1 ` H9 E% N, V u. P; vhyperplasia is the 21-hydroxylase enzyme deficiency.
4 {: D9 Z* b* ?! e5 Z6 \6 OThe 11-β hydroxylase deficiency may also result in6 h( T5 R2 t/ a( j- T
excessive adrenal androgen production, and rarely,# e& q/ e; ]. p! ~% C
an adrenal tumor may also cause adrenal androgen
. G% R9 L* k, ?5 K( |+ @excess.1,33 d$ ]7 [# N% I g& \+ |
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. r5 M8 k: F2 R' n% |3 l$ f0 u. C4 N542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; U) m. z4 _3 f7 Q6 |9 c$ yA unique entity of male-limited gonadotropin-
$ X; f, Y$ U. iindependent precocious puberty, which is also known# s$ ~/ G2 P! M
as testotoxicosis, may cause precocious puberty at a
+ I3 Q( M4 X2 a. {; g F; ~very young age. The physical findings in these boys
( i& B$ }; C4 e) B, Iwith this disorder are full pubertal development,* q0 _+ j7 |. _7 a
including bilateral testicular growth, similar to boys& O! a) Z, j& o
with CPP. The gonadotropin levels in this disorder
) i3 `- H) j6 S, A# Pare suppressed to prepubertal levels and do not show
3 o& K# |, M& ?' Spubertal response of gonadotropin after gonadotropin-
4 a3 ^1 R/ {% k6 ]% y; e0 g5 ]$ d% w5 m& Areleasing hormone stimulation. This is a sex-linked
* ?% T+ b9 f; R' N lautosomal dominant disorder that affects only
. i" g: ~, {+ P. B4 `6 {males; therefore, other male members of the family
7 ]& u; n- O" n6 q# imay have similar precocious puberty.3
/ I- x* w5 p# SIn our patient, physical examination was incon-8 o; {/ k+ f0 P) {9 ^' b
sistent with true precocious puberty since his testi-( g% }9 f! ~. z2 X- R7 L) ^
cles were prepubertal in size. However, testotoxicosis
& e) c m+ T0 }9 gwas in the differential diagnosis because his father$ E/ m0 e e' r9 U
started puberty somewhat early, and occasionally,. U; l" [6 Z9 B& M
testicular enlargement is not that evident in the* ~. c/ N# ?" L, [
beginning of this process.1 In the absence of a neg-
, ^) T7 _2 c& L! u" e( [ative initial history of androgen exposure, our
& H* [+ a9 q! ]; F6 B2 A0 Ubiggest concern was virilizing adrenal hyperplasia,
9 N8 S- i) L6 F- O3 F, [either 21-hydroxylase deficiency or 11-β hydroxylase
0 e! s; r4 T* W% m b- Adeficiency. Those diagnoses were excluded by find-' }% c% X- U+ [; O: ]5 c: T
ing the normal level of adrenal steroids.
0 T' e, e1 Z! u* _The diagnosis of exogenous androgens was strongly% D$ J; h( X( K% K6 {
suspected in a follow-up visit after 4 months because/ V) x, t3 t3 Z. W
the physical examination revealed the complete disap-! t# R' w6 t$ V$ e/ D- E
pearance of pubic hair, normal growth velocity, and2 e) {8 w; q! h% |& r3 G( R
decreased erections. The father admitted using a testos-: G' T- U! @" n
terone gel, which he concealed at first visit. He was; G% H) G8 I, Q1 S* v
using it rather frequently, twice a day. The Physicians’6 j+ H7 p% `' W5 ^" U: g7 J
Desk Reference, or package insert of this product, gel or X; W: f! k9 j' c4 I) y
cream, cautions about dermal testosterone transfer to6 K$ m5 ]) E/ X5 }; N
unprotected females through direct skin exposure.
" i% L5 p1 [+ R0 uSerum testosterone level was found to be 2 times the' Z, o" h5 Y# B% Q
baseline value in those females who were exposed to
4 m2 \+ \8 K* }1 H: i" x3 R( r" y) T9 teven 15 minutes of direct skin contact with their male" L8 v4 d/ |* f/ P8 C8 M
partners.6 However, when a shirt covered the applica-% ?) |6 T7 }: \
tion site, this testosterone transfer was prevented." a/ S; E5 b2 ]2 |* O; }$ h
Our patient’s testosterone level was 60 ng/mL,
0 A% K6 x; \* `8 {which was clearly high. Some studies suggest that- q+ _- M! x6 n# n
dermal conversion of testosterone to dihydrotestos-: p% j) n1 y! \
terone, which is a more potent metabolite, is more$ m% g) Q* r4 i$ r- I9 M8 y Y O
active in young children exposed to testosterone
# _1 q9 [$ h2 ]0 t& dexogenously7; however, we did not measure a dihy-1 d* c- F E: R) e
drotestosterone level in our patient. In addition to
, z' e. w# h3 q) P: y n/ Avirilization, exposure to exogenous testosterone in' F4 y5 J, G! z/ D; H
children results in an increase in growth velocity and2 Y! Q$ ~# E/ |
advanced bone age, as seen in our patient." K! D% a" `) Z( M4 ?
The long-term effect of androgen exposure during
& V/ R ^# u) E5 n7 F+ N7 t2 S! d, _early childhood on pubertal development and final: q! Q! g+ l9 G/ _. s2 }
adult height are not fully known and always remain, Y ^, \6 Q; O- P2 t3 \. v
a concern. Children treated with short-term testos-
2 L' [0 s4 g' c2 gterone injection or topical androgen may exhibit some
: ~8 E$ }( B" _& g- Eacceleration of the skeletal maturation; however, after$ B2 e6 v, z' R, r' @4 S" R/ g
cessation of treatment, the rate of bone maturation
) E) B+ I( k+ ~3 G A% s7 C4 V2 Ldecelerates and gradually returns to normal.8,96 m& {' {# N7 \+ H7 t" W* H
There are conflicting reports and controversy
4 C; l+ f8 ^5 Q5 c |, [- wover the effect of early androgen exposure on adult2 h6 `& G. _+ \4 w r: {
penile length.10,11 Some reports suggest subnormal
% ?9 N. N/ L3 C W5 Madult penile length, apparently because of downreg-
/ t# U- B6 D( q5 g+ ?6 Bulation of androgen receptor number.10,12 However,9 o& c U' S4 S9 U: p
Sutherland et al13 did not find a correlation between
, t. r' w" J$ M2 {- O: dchildhood testosterone exposure and reduced adult* h+ I+ _2 d) d' W7 I, \
penile length in clinical studies.
3 ?7 K! R5 r2 bNonetheless, we do not believe our patient is
! N5 [+ M# P/ I Ogoing to experience any of the untoward effects from/ {: R! Y* }6 \, J8 L8 _+ u
testosterone exposure as mentioned earlier because
0 M H$ D! r& Athe exposure was not for a prolonged period of time.
3 l5 [1 b% r6 Y/ V( Q- f3 \Although the bone age was advanced at the time of
0 |3 M. w+ h6 M" W$ Y) fdiagnosis, the child had a normal growth velocity at
6 }* x8 m& b7 A7 z( f# qthe follow-up visit. It is hoped that his final adult# o% i8 I- j5 f3 V/ Y' O2 Q
height will not be affected.
+ L P/ G# N7 m6 @% x! C E% ]Although rarely reported, the widespread avail-/ H0 H6 ` d2 f. N# w2 J: w
ability of androgen products in our society may1 c9 ?4 V/ p% z+ d' ?
indeed cause more virilization in male or female
: V6 G7 J. }! S5 U4 U$ j3 q# O! tchildren than one would realize. Exposure to andro-
7 s3 o/ Z' P! w9 b& @" e6 Fgen products must be considered and specific ques-3 \# R3 y# [) ~) _# C* C
tioning about the use of a testosterone product or
! O$ v t Z* J9 G1 I; igel should be asked of the family members during1 y2 L6 S6 G% h; `5 N6 o; r4 f' M
the evaluation of any children who present with vir-" I3 D. T; P4 K/ t$ e
ilization or peripheral precocious puberty. The diag-) D! l6 ]( M) @2 a9 A" k8 e
nosis can be established by just a few tests and by5 C9 W, a. X& b- Z f
appropriate history. The inability to obtain such a
: y% |! N% s! i, k$ J- h4 i& }& hhistory, or failure to ask the specific questions, may5 a* V8 l: x) I6 x8 I5 H
result in extensive, unnecessary, and expensive; Y7 ^( z$ @# _
investigation. The primary care physician should be
* a% K* ~& g! o+ {! B* _2 iaware of this fact, because most of these children; z" e; B, ]2 `0 C* h3 d
may initially present in their practice. The Physicians’/ w7 u; p+ p+ Q# r( z5 v' ] z* N. |
Desk Reference and package insert should also put a
( j( l3 F8 l2 ], S' {warning about the virilizing effect on a male or
- ~* D+ [* \ Rfemale child who might come in contact with some-
/ D* A- z9 F, J9 ~+ `) d# Jone using any of these products.
6 J# k7 ]) j3 D4 ]References0 ~; E! Z% o9 y9 ^6 ~' N
1. Styne DM. The testes: disorder of sexual differentiation" ]( H- f8 d( T1 E- k& }
and puberty in the male. In: Sperling MA, ed. Pediatric
2 O( E/ k: m( ~4 O$ o% C/ n d5 g DEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
* ^4 p0 E8 Y: q8 x1 b2002: 565-628.
4 W8 w7 l3 t; p! q9 }" b3 V. N U2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) h/ q& J' t5 |0 x$ j+ p5 N
puberty in children with tumours of the suprasellar pineal |
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