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Sexual Precocity in a 16-Month-Old) Q7 x& X) d7 ?8 V1 y$ L' D& F. y; L
Boy Induced by Indirect Topical+ @# a4 u' a2 M( @4 u
Exposure to Testosterone
. j& A3 Z1 U/ F& d7 u& [Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! O& F M( t8 C0 W, t2 m5 N9 O
and Kenneth R. Rettig, MD1
9 K, P& j9 l1 D6 H" d2 F uClinical Pediatrics) {9 F" j# V# l6 Y
Volume 46 Number 6, U% Z; z6 J% a: t, p/ P* _4 F
July 2007 540-543
5 E0 l/ r+ j$ ?© 2007 Sage Publications
) t& ]5 X4 v* ]10.1177/0009922806296651$ I; D, S y$ A1 u" g/ f7 q
http://clp.sagepub.com3 s2 ~4 v+ R( c7 c2 m1 m
hosted at
. j. T. M$ p1 g5 g: l) c8 Ohttp://online.sagepub.com
; R+ m( L' W, |: DPrecocious puberty in boys, central or peripheral,! R# A; h! J0 K4 T
is a significant concern for physicians. Central: M, p" W& Z4 S* K
precocious puberty (CPP), which is mediated
0 m% z) Q! v+ V! \3 m3 rthrough the hypothalamic pituitary gonadal axis, has5 K- {& D) D1 M6 I4 f" `% H
a higher incidence of organic central nervous system7 U( I1 I3 ~$ N) S
lesions in boys.1,2 Virilization in boys, as manifested
1 l4 x; Q+ x6 v$ M) @ l1 y. T- Hby enlargement of the penis, development of pubic* u: v) b1 S, P( P1 n
hair, and facial acne without enlargement of testi-% N, \, c" Q1 k& n8 ]
cles, suggests peripheral or pseudopuberty.1-3 We- O+ H- v) E' F A$ p' q) _
report a 16-month-old boy who presented with the# z) P% P' S; O2 \
enlargement of the phallus and pubic hair develop-
; r6 h3 b+ o7 F: d+ m, T. lment without testicular enlargement, which was due5 D1 ^! i2 f, `
to the unintentional exposure to androgen gel used by
5 D1 R! E1 q2 T8 r, j. o+ j0 X# Ithe father. The family initially concealed this infor-4 ^- W/ g' O6 T
mation, resulting in an extensive work-up for this+ t# y' F7 d8 Z1 U6 s) p0 @
child. Given the widespread and easy availability of
3 o, d: D; x+ Etestosterone gel and cream, we believe this is proba-
8 d5 t9 j- I+ n9 V' w) Rbly more common than the rare case report in the: o }6 v6 G3 l" y2 A9 `- L
literature.48 W) M6 U Z, u0 M& o t
Patient Report
9 Z- j# k" t9 N1 k. WA 16-month-old white child was referred to the# N( y* V# [4 f/ f4 @: A
endocrine clinic by his pediatrician with the concern4 F& I$ p( U( \* \/ U: z( J+ m
of early sexual development. His mother noticed# H$ R# M' U5 ]" \* c" w
light colored pubic hair development when he was
- M' W; P+ D0 x7 V4 [From the 1Division of Pediatric Endocrinology, 2University of1 N$ A/ V) P" J+ H' Y& w
South Alabama Medical Center, Mobile, Alabama.
$ t4 ^8 A% L& u# e- H: MAddress correspondence to: Samar K. Bhowmick, MD, FACE,
( E+ |/ @8 [9 B( z+ bProfessor of Pediatrics, University of South Alabama, College of6 A5 D$ f" E5 @" B$ \( L L
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;: t. ]5 M5 A* O2 e
e-mail: [email protected].
0 H! k; i, [/ d) w0 T' `; wabout 6 to 7 months old, which progressively became
! O0 _4 B3 \3 p+ e& Q* Sdarker. She was also concerned about the enlarge-5 o* a, a1 o3 C! B
ment of his penis and frequent erections. The child
4 T8 L1 G( g$ P3 y/ Y* cwas the product of a full-term normal delivery, with" ~- z: [# M! R3 M$ O, u" a
a birth weight of 7 lb 14 oz, and birth length of; j2 h6 b! p; F B9 Q
20 inches. He was breast-fed throughout the first year
' U3 P% W& T4 t+ qof life and was still receiving breast milk along with% V, n) d" ^- D6 |+ B
solid food. He had no hospitalizations or surgery,
3 Y8 n) o* \9 q+ L$ y* a9 zand his psychosocial and psychomotor development, A3 K, r* b% ?3 Q* k
was age appropriate./ u( w$ U% D c; ^4 L, v
The family history was remarkable for the father,
" s3 M7 v q1 l' uwho was diagnosed with hypothyroidism at age 16,
0 G5 Y2 X6 o* k' d/ pwhich was treated with thyroxine. The father’s
+ W# v p* a& {# c ^( Y) Nheight was 6 feet, and he went through a somewhat
# j4 y. G! w0 z+ }, a/ Z+ a! |% a7 P' eearly puberty and had stopped growing by age 14.
3 O3 m m% f+ i, ]9 |% N/ r8 `The father denied taking any other medication. The
u+ g% P. Y- Y" d0 b. h5 `3 w3 qchild’s mother was in good health. Her menarche j7 U: D8 E, F7 S z! y
was at 11 years of age, and her height was at 5 feet- H( B# Q' w/ |' j
5 inches. There was no other family history of pre-
: k4 ^. n. s0 i5 V4 zcocious sexual development in the first-degree rela-* T8 d. `; ]5 w6 ] j% n2 l! a: n
tives. There were no siblings.
# O2 Y3 [2 a# ^% L/ ^Physical Examination
; e- z+ ?- o5 n* E: X U, z- I& fThe physical examination revealed a very active,0 y, j0 w- e, @2 w, X& s5 \, o
playful, and healthy boy. The vital signs documented1 i. h' X& D/ | [ A U" _
a blood pressure of 85/50 mm Hg, his length was/ U8 C% p. o" p$ j
90 cm (>97th percentile), and his weight was 14.4 kg( d K' C) m* M e8 {
(also >97th percentile). The observed yearly growth
1 i5 g/ u& v8 u3 A% I4 ^5 Bvelocity was 30 cm (12 inches). The examination of
* l$ u0 _+ @ Athe neck revealed no thyroid enlargement.
6 z0 b5 ]' x4 _/ y, n; HThe genitourinary examination was remarkable for) X% d, F, U4 x
enlargement of the penis, with a stretched length of
T- N* v$ F, m8 cm and a width of 2 cm. The glans penis was very well
/ q* Z5 Z, a7 |1 kdeveloped. The pubic hair was Tanner II, mostly around
7 H$ s6 u; P& a540 p! D# L( i+ b; ~9 k* S' n7 d% H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% s. D9 ^- D* k% l- f- `6 Qthe base of the phallus and was dark and curled. The
3 T/ A+ m' L2 N$ ntesticular volume was prepubertal at 2 mL each.+ e. g4 o* Y% Y) }
The skin was moist and smooth and somewhat
$ X) e( q6 ^ s( M. k$ Z: N1 ~oily. No axillary hair was noted. There were no* O, ?' M) v) X7 W
abnormal skin pigmentations or café-au-lait spots.( D- S/ i! q- K: P1 d- J
Neurologic evaluation showed deep tendon reflex 2+
9 u# z7 p( p3 d$ w# Y/ x: y7 Bbilateral and symmetrical. There was no suggestion) \* p: G' B+ v+ F3 N
of papilledema.& c, P. X1 |2 A' d [* {
Laboratory Evaluation
9 Q7 g- q; Z; L ?, K( B2 I1 OThe bone age was consistent with 28 months by
( N9 j* A! [1 q8 susing the standard of Greulich and Pyle at a chrono-& i( j- y; N( W4 F, r
logic age of 16 months (advanced).5 Chromosomal5 d8 h6 h. X" Q
karyotype was 46XY. The thyroid function test
, P/ C5 {: t9 F+ `5 O$ h5 Tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 |. E( N3 T4 Y
lating hormone level was 1.3 µIU/mL (both normal).2 e) D" s! Z( B% Z# H8 o& c
The concentrations of serum electrolytes, blood# z- v$ b) `6 k3 \
urea nitrogen, creatinine, and calcium all were
! p9 q( j, A/ Cwithin normal range for his age. The concentration0 U* Z- q: |; k! l$ q/ ^# f3 b
of serum 17-hydroxyprogesterone was 16 ng/dL; D6 A! r9 s1 U3 [6 ?. B
(normal, 3 to 90 ng/dL), androstenedione was 20/ Q1 {: C" V. [+ g- w' C" t) \5 r
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) O) d# c. ?; Nterone was 38 ng/dL (normal, 50 to 760 ng/dL),
! N( g! b& A0 G' {/ r; n3 tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ U4 w( p3 Y' P( x# I49ng/dL), 11-desoxycortisol (specific compound S)
7 v- R0 Z X' }1 I3 W4 [& Cwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- O* i& ~' Q( a0 N: q: p" K
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# K: z* J* t W9 s! M Z0 h; N& |
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),0 G# z+ l! o, V. c
and β-human chorionic gonadotropin was less than
* j+ N- A: l! O3 y" Q5 mIU/mL (normal <5 mIU/mL). Serum follicular
) P0 H7 G7 U& w: mstimulating hormone and leuteinizing hormone
' _6 F2 w) b( ^/ |+ T! Pconcentrations were less than 0.05 mIU/mL
) _8 D- p' R- Q8 t% {(prepubertal).! z4 i4 f8 r. ^5 K2 ?8 y
The parents were notified about the laboratory0 o) A: y* E" f& F
results and were informed that all of the tests were0 g' v- F$ g1 Z' _; v. D8 K
normal except the testosterone level was high. The- P" ^- a8 f. R( y9 [; i7 w
follow-up visit was arranged within a few weeks to; K3 }% z; f* y, K3 E/ v9 c
obtain testicular and abdominal sonograms; how-
- e7 S& \' v6 tever, the family did not return for 4 months.
; v" @5 P# W ]6 Y6 e2 s: Z. f( NPhysical examination at this time revealed that the
* g5 m3 }' |* T# p1 C" H8 Xchild had grown 2.5 cm in 4 months and had gained- J0 A( Z7 }% j/ K( {& p
2 kg of weight. Physical examination remained. }" i$ M+ Y) `* x
unchanged. Surprisingly, the pubic hair almost com-' [1 }2 e/ q) c
pletely disappeared except for a few vellous hairs at: f. @& F" j8 C) l" U
the base of the phallus. Testicular volume was still 2% F1 S3 H, Q$ U4 a# B7 ^$ I- @
mL, and the size of the penis remained unchanged.8 ~6 ~6 L$ A0 v6 d
The mother also said that the boy was no longer hav-
; `( ?) A$ t$ S) D g: d, z* hing frequent erections.
4 w7 `% q$ _+ \7 \Both parents were again questioned about use of
) n# c2 _) a, A, ~1 a8 Many ointment/creams that they may have applied to6 n, N, j/ h6 V9 k
the child’s skin. This time the father admitted the
; `6 W! ~3 M- Z- q) Y8 M2 i* T# }Topical Testosterone Exposure / Bhowmick et al 541
* V2 b6 V2 x- `& X+ ^ E/ Yuse of testosterone gel twice daily that he was apply-$ I/ t7 G. I, h; A# m _
ing over his own shoulders, chest, and back area for. L4 F; y$ U0 |* I; W1 I7 Z
a year. The father also revealed he was embarrassed! I& d$ f: F! U6 I
to disclose that he was using a testosterone gel pre-; j% E1 ?2 d y
scribed by his family physician for decreased libido/ i& u7 Q: K7 f8 B
secondary to depression.
; T3 Q5 ?! m* {3 \+ t3 VThe child slept in the same bed with parents.
6 g/ P4 c% x# V5 j0 bThe father would hug the baby and hold him on his
3 F) r& [" L% kchest for a considerable period of time, causing sig-: d" b# v& s; f C* S' L8 k. i
nificant bare skin contact between baby and father.# m+ R( L9 l2 d2 ]# n. `% O
The father also admitted that after the phone call,5 V# V9 ?; u. q O2 C. _( x) R
when he learned the testosterone level in the baby
& h4 r' i( o }was high, he then read the product information
7 j' x: X8 {3 V# z6 opacket and concluded that it was most likely the rea-
; M1 N6 b" @) L2 J3 C) ]son for the child’s virilization. At that time, they# [4 R4 D$ Z& v9 e( n
decided to put the baby in a separate bed, and the3 G& O& ^! `1 M) y9 c& w: r
father was not hugging him with bare skin and had
, x2 [ @ c3 d8 n" u& _) a6 }0 sbeen using protective clothing. A repeat testosterone
+ E* z7 h- o9 S$ v* Dtest was ordered, but the family did not go to the$ Y! U; i$ R7 l! t" E
laboratory to obtain the test.4 o, m6 ?( v( k, h% _7 s Z2 R* k
Discussion
& y# \ L1 A' T$ l& XPrecocious puberty in boys is defined as secondary! r2 i; o4 @/ o2 Z* M& y2 Z1 X9 x
sexual development before 9 years of age.1,47 W u% A$ Z9 d, Y
Precocious puberty is termed as central (true) when
' @0 v7 C! T2 ]; c! }# uit is caused by the premature activation of hypo-
: v" ~; Z5 Q; ~; P6 w7 ]; D% @thalamic pituitary gonadal axis. CPP is more com-
- @3 w) P: Z7 T- H, ~8 ]3 |mon in girls than in boys.1,3 Most boys with CPP) N6 |% j. V% f, K0 V% L/ i
may have a central nervous system lesion that is+ @0 N+ `2 k9 \- c7 ]; }( n9 A
responsible for the early activation of the hypothal-
7 x% a; d$ J) U- ?amic pituitary gonadal axis.1-3 Thus, greater empha-
; I H+ }4 W2 w6 G' Csis has been given to neuroradiologic imaging in$ p2 p1 m% [7 Q# n
boys with precocious puberty. In addition to viril- ^& o. J7 F% K" N% J
ization, the clinical hallmark of CPP is the symmet-7 v; _$ Q' q7 J$ f. o0 G8 g
rical testicular growth secondary to stimulation by- `" G* K- u5 N' b/ Q
gonadotropins.1,3! R: s/ S! O1 w3 g: ]% z$ c5 W5 f
Gonadotropin-independent peripheral preco-+ N+ Y0 A$ M O' v( z. c
cious puberty in boys also results from inappropriate
$ x+ A3 @ S) b4 ~, | c* S" n- ]androgenic stimulation from either endogenous or0 ~+ r1 e/ T( ^- y/ \
exogenous sources, nonpituitary gonadotropin stim-7 L/ m- f( q+ E* ]
ulation, and rare activating mutations.3 Virilizing: Z( {& b. Z& ~0 C4 e6 t4 e
congenital adrenal hyperplasia producing excessive3 v8 `7 u& a$ E: l
adrenal androgens is a common cause of precocious
3 W! Y; v* j8 fpuberty in boys.3,4) s& V, S' k$ E# B7 B- [
The most common form of congenital adrenal
+ ~9 |6 ^ b" b( L4 l$ Nhyperplasia is the 21-hydroxylase enzyme deficiency.+ g# Z3 f* i9 l4 V) l l. E. I: @
The 11-β hydroxylase deficiency may also result in7 C: x v" e. U" Y. `
excessive adrenal androgen production, and rarely,: N# f) j+ G) [ {$ k
an adrenal tumor may also cause adrenal androgen, X! P2 v) k( _% e. N
excess.1,3; V: H! z* K! y) B& |
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) X% l$ I$ {; w/ K" _3 a/ w542 Clinical Pediatrics / Vol. 46, No. 6, July 2007+ Y# J0 e; P* Z. a* ]( l8 d
A unique entity of male-limited gonadotropin-
4 p7 L! Z& `+ @ D) O# b% F7 Tindependent precocious puberty, which is also known; ^& j6 H0 c* ?0 W9 h; |
as testotoxicosis, may cause precocious puberty at a1 N/ B$ G' l) G9 C' I- Z& A
very young age. The physical findings in these boys
. e$ l# D6 d o9 ~with this disorder are full pubertal development,. ^6 i- W9 D4 U) ~
including bilateral testicular growth, similar to boys
, e0 L7 s& _+ F. k4 ^$ nwith CPP. The gonadotropin levels in this disorder
; k. D) ^5 z7 n; Sare suppressed to prepubertal levels and do not show( z& Q, y. h* O8 c {: Y
pubertal response of gonadotropin after gonadotropin-! D4 A e; k5 U* i, O1 i. P; C
releasing hormone stimulation. This is a sex-linked7 {# `2 ? [+ K
autosomal dominant disorder that affects only+ V9 S* {3 Y1 C" b
males; therefore, other male members of the family2 E& l7 s3 s+ Q Q9 l( l
may have similar precocious puberty.3
3 t' b) O* x; i4 LIn our patient, physical examination was incon-
9 y& i; }2 C) U0 Bsistent with true precocious puberty since his testi-* _9 H$ g: @6 o' c) C ^ x3 |
cles were prepubertal in size. However, testotoxicosis
" C; W: _: H! _ F# q6 f" ^0 awas in the differential diagnosis because his father5 P2 a* F" I" ?) R! U
started puberty somewhat early, and occasionally,
1 O g( a* F) k, ]5 t; H [* ttesticular enlargement is not that evident in the9 Q' a6 }. c' Y$ G
beginning of this process.1 In the absence of a neg-2 n0 {' ~1 ~9 w# g
ative initial history of androgen exposure, our
4 A( c, {6 B: V# h: lbiggest concern was virilizing adrenal hyperplasia,. L6 o( \% P. U. T
either 21-hydroxylase deficiency or 11-β hydroxylase
) \' ^' [+ E- E) C8 Vdeficiency. Those diagnoses were excluded by find-& o) M& c; O, S3 Y5 \' E# I, y/ r% v
ing the normal level of adrenal steroids." C) D: z, n; ?
The diagnosis of exogenous androgens was strongly/ U$ ]( z2 g! b2 W& K
suspected in a follow-up visit after 4 months because
9 A" C8 ]. U' \the physical examination revealed the complete disap-
1 `# @# K: d" l) x Dpearance of pubic hair, normal growth velocity, and
3 ~6 n, G; {3 d9 |" ldecreased erections. The father admitted using a testos-2 _! B0 C# n, j) B. q. \
terone gel, which he concealed at first visit. He was. Q: ?% y& H: p- s
using it rather frequently, twice a day. The Physicians’# Y9 W9 E3 |4 c* g9 `3 y6 f9 a
Desk Reference, or package insert of this product, gel or- f* g# X" w% H
cream, cautions about dermal testosterone transfer to
$ L. L4 k3 Z; ^. N; sunprotected females through direct skin exposure.
- U. G1 s% K1 b' v) ^Serum testosterone level was found to be 2 times the
- V6 @% d1 x7 _8 n; L; Nbaseline value in those females who were exposed to
" v8 I/ h. n2 v- Weven 15 minutes of direct skin contact with their male
6 N7 J0 e ` |& d& Epartners.6 However, when a shirt covered the applica-
( o S$ n5 o. c8 Stion site, this testosterone transfer was prevented.
- }3 N+ E' D4 B9 a3 nOur patient’s testosterone level was 60 ng/mL,
4 n: K. g7 A# Y0 }9 Nwhich was clearly high. Some studies suggest that+ G" j6 X& E% k* M) c4 b- d4 t
dermal conversion of testosterone to dihydrotestos-
8 E q' g+ S( Q* b7 W9 Qterone, which is a more potent metabolite, is more; F' d% B3 m6 ~+ ?0 n1 L; Y5 P
active in young children exposed to testosterone
+ L3 a& p' U, Z$ ~( i5 xexogenously7; however, we did not measure a dihy-
* R$ p( y. @/ n- ?% w/ V7 mdrotestosterone level in our patient. In addition to n2 V/ B" p# s5 {; P
virilization, exposure to exogenous testosterone in
# u4 k3 n# i5 r7 Z' {children results in an increase in growth velocity and1 T! \. X5 j/ X+ z
advanced bone age, as seen in our patient.
& Y; l3 e" g: i4 ] ^5 ^The long-term effect of androgen exposure during
2 I. I1 e! H: K5 f* r( Oearly childhood on pubertal development and final+ l6 `: M( H6 G- p4 r; a
adult height are not fully known and always remain
8 H. z4 M) y' d3 P/ ?7 [( |" Ja concern. Children treated with short-term testos-, {! @% Z% c; Z4 `9 T
terone injection or topical androgen may exhibit some
7 u5 Z8 F" A5 F# facceleration of the skeletal maturation; however, after
/ d9 ~+ @5 V: V' m0 M5 H7 @cessation of treatment, the rate of bone maturation& r6 l# l; o% i
decelerates and gradually returns to normal.8,9
5 D9 K% B+ c6 ?/ e! O; SThere are conflicting reports and controversy e# R' J7 m0 k0 R) [/ ^
over the effect of early androgen exposure on adult
; E8 w( V# A$ h3 @penile length.10,11 Some reports suggest subnormal! z, B: h Q! @8 l# E. D2 U
adult penile length, apparently because of downreg-. ?, o0 Y9 h! ~3 @8 S5 G6 [0 ^
ulation of androgen receptor number.10,12 However,
. Z* K7 H9 q0 x- V0 QSutherland et al13 did not find a correlation between/ s, o5 w+ l2 ` q$ U; J( v
childhood testosterone exposure and reduced adult3 n* S0 a/ ?3 l4 g6 a( {
penile length in clinical studies., r4 f, G% c3 _$ s- x
Nonetheless, we do not believe our patient is
' i! w# G( X$ i6 P; G' sgoing to experience any of the untoward effects from% v( s0 b( Q; B- b7 [9 G1 R
testosterone exposure as mentioned earlier because! X# v5 ^6 y4 t2 s' i X$ \
the exposure was not for a prolonged period of time.) o! Q! J5 P9 P3 E7 u. |
Although the bone age was advanced at the time of7 s$ @- g& m$ k' u; k! n+ D6 F5 D
diagnosis, the child had a normal growth velocity at4 o& W) V h8 }, I y, H G
the follow-up visit. It is hoped that his final adult( o0 s7 M/ `& P. U j _, O
height will not be affected.. t9 ]0 L b' j
Although rarely reported, the widespread avail-7 g3 B+ r8 B3 g, l6 H+ \
ability of androgen products in our society may
0 F4 q& _) x/ P% r. y: Hindeed cause more virilization in male or female% T% c' G1 {3 {# }/ M: E. {. I% ]9 ^
children than one would realize. Exposure to andro-' t8 p$ c0 `, Y; s. }
gen products must be considered and specific ques-; |) ]4 r+ v# p5 u
tioning about the use of a testosterone product or
( M" o) S2 ?/ Agel should be asked of the family members during
7 ?* Y+ S* }9 X8 t7 i2 O: Qthe evaluation of any children who present with vir-5 L' X. _" `# U7 F6 d$ z
ilization or peripheral precocious puberty. The diag-
a2 z( Z) r+ |% Z% A' i E6 T" znosis can be established by just a few tests and by* M* A4 I1 b6 z7 E H# _) B
appropriate history. The inability to obtain such a
7 [& B% x( a* Shistory, or failure to ask the specific questions, may
3 s* @2 W U- Z2 a6 X' M5 oresult in extensive, unnecessary, and expensive4 g* \3 W6 u8 D
investigation. The primary care physician should be# f$ y" {$ U" X( J7 u
aware of this fact, because most of these children
6 n6 k# r/ D, a; A4 G- _may initially present in their practice. The Physicians’
4 n7 J- c, [: U- [( W xDesk Reference and package insert should also put a
7 F: ?1 h! H8 r( f) K+ fwarning about the virilizing effect on a male or' ^7 D3 d* p6 `& j$ Y
female child who might come in contact with some-
4 m, \: v" r: B) Q$ u1 oone using any of these products.5 z; e! E' ]: O3 I0 }8 e+ z0 l; {
References
1 h% e$ |0 f6 U! W' Q, P% S1. Styne DM. The testes: disorder of sexual differentiation
% H2 @! G4 X! g4 H. Mand puberty in the male. In: Sperling MA, ed. Pediatric, V5 ]! Y9 h% i4 y$ |, b
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. f; O" {" w/ ^# ]! |$ W0 J
2002: 565-628.
' a- K" z" q$ h% d, s% P, P2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 @: M. B5 b |: ]" o3 |6 S: jpuberty in children with tumours of the suprasellar pineal |
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