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Sexual Precocity in a 16-Month-Old+ O; X- v0 z3 {( h
Boy Induced by Indirect Topical
! c8 _6 F% F" S& G0 d9 q0 R* kExposure to Testosterone1 \+ ]# P8 d1 b) ?0 _
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ ]" K8 {* O N4 yand Kenneth R. Rettig, MD1( q7 }# l, ], u/ y
Clinical Pediatrics
$ g9 i$ K: v, T, w# F4 q- lVolume 46 Number 6. Q/ D* W7 [* l- K9 @3 X
July 2007 540-543
/ R& i2 X: j6 \5 L6 S# q4 @' L, F% {© 2007 Sage Publications# {" i/ w1 Q( G4 ~! R
10.1177/00099228062966515 f$ O) m9 n" X
http://clp.sagepub.com
4 @8 j+ O2 W& r" ^! Khosted at+ L" L, K4 c( A3 ~, @$ p7 Y
http://online.sagepub.com) _8 O, x0 v7 {' I1 ~# @
Precocious puberty in boys, central or peripheral,
: I% J6 X1 ]5 r9 Q$ \is a significant concern for physicians. Central
+ F$ J X* W8 ~( P9 C( @precocious puberty (CPP), which is mediated
: {' f$ L" t5 lthrough the hypothalamic pituitary gonadal axis, has% z; }* I; C0 W0 g7 B: l
a higher incidence of organic central nervous system
. ?: m) p+ R: u. \lesions in boys.1,2 Virilization in boys, as manifested4 }+ s& V% a; q2 t/ a
by enlargement of the penis, development of pubic$ z' K% R3 n' K& I, m# J4 |7 y
hair, and facial acne without enlargement of testi-
$ i) C' m" {& r, c/ hcles, suggests peripheral or pseudopuberty.1-3 We3 w$ Y$ [. A' O" i8 j' Y
report a 16-month-old boy who presented with the( J: P0 A( `" _1 p' s. M" Q
enlargement of the phallus and pubic hair develop-
, Z8 h$ [' R( u' u! sment without testicular enlargement, which was due
& T% M+ X* m7 ito the unintentional exposure to androgen gel used by- I7 b( I" |; } ~( S% f. o& U
the father. The family initially concealed this infor-
8 |; L( d. |! J) s; u; Y. ^mation, resulting in an extensive work-up for this4 V; S/ n1 z1 M+ x
child. Given the widespread and easy availability of
7 Z7 T6 h# K' k) x9 m4 J7 ]testosterone gel and cream, we believe this is proba-
8 b3 q4 T3 [8 p% _: C( pbly more common than the rare case report in the
. ] P* G! f& B" R* O) Hliterature.4+ Z" |) t, H7 g# l% d
Patient Report
6 U. o% e5 G" L; H8 ~0 {A 16-month-old white child was referred to the
. O d- X8 L* ]9 f6 j jendocrine clinic by his pediatrician with the concern, i/ q, _1 H' H. D3 K
of early sexual development. His mother noticed# N3 ]( R1 h9 ^' R" V5 ]
light colored pubic hair development when he was
3 e$ v" |3 p/ i2 @3 XFrom the 1Division of Pediatric Endocrinology, 2University of) z1 U' U" Y5 B
South Alabama Medical Center, Mobile, Alabama.
' e' ^7 b% v# M2 MAddress correspondence to: Samar K. Bhowmick, MD, FACE,
/ o: W+ B% ~: R( @: V& i/ k6 [Professor of Pediatrics, University of South Alabama, College of8 I0 A# [3 L$ c% _# |
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- Q5 ~& M- p) t0 K$ i9 q0 Y) X* D
e-mail: [email protected].
$ V% L" ]/ P) `# ?: Babout 6 to 7 months old, which progressively became% V2 J: O$ A4 A
darker. She was also concerned about the enlarge-
0 t2 d) m7 h) _8 v% A* Bment of his penis and frequent erections. The child6 U, G2 g& } t$ V/ A' Z8 [
was the product of a full-term normal delivery, with
8 N. B$ ?, g0 D/ F' R# ]5 [a birth weight of 7 lb 14 oz, and birth length of0 Q) I( C5 l" d0 J- B$ q! Z. B* f
20 inches. He was breast-fed throughout the first year
7 C: a' M! b- a6 X4 Aof life and was still receiving breast milk along with
( M, |/ R7 i/ o* }. Zsolid food. He had no hospitalizations or surgery,3 `5 l9 Y$ I( |0 u# e
and his psychosocial and psychomotor development: t9 K2 V% J, @, D! V+ R" B4 q6 V
was age appropriate.
: V3 M, V' W# S: x# r3 h2 V ~The family history was remarkable for the father,, L# p, P" B8 g8 l/ F2 ]6 h0 S
who was diagnosed with hypothyroidism at age 16,
$ q' `0 D/ }/ x- D" [which was treated with thyroxine. The father’s
6 Z& c5 W- }0 x! I) k8 \0 aheight was 6 feet, and he went through a somewhat
8 [ _4 `2 r2 u1 i: H( n f7 ?- Gearly puberty and had stopped growing by age 14./ a2 i; O% S/ [, Z G& y
The father denied taking any other medication. The1 }9 t5 O. \; n' i( V8 P
child’s mother was in good health. Her menarche
7 @# w- F' D! _9 Nwas at 11 years of age, and her height was at 5 feet' R2 s" R* {) L4 Y1 N
5 inches. There was no other family history of pre-
" s. l! o" e3 E6 a: {# Ecocious sexual development in the first-degree rela-
8 ^( z& `- T+ Utives. There were no siblings.9 I% |3 }" R) x3 D0 X
Physical Examination
. b& L- F, h0 J" b; H! cThe physical examination revealed a very active,* m2 D8 c4 }; @* D
playful, and healthy boy. The vital signs documented
3 V$ @! T3 E+ z+ n$ K+ ~: c$ Y8 Ia blood pressure of 85/50 mm Hg, his length was9 @$ H& @+ f, R* O7 I4 u
90 cm (>97th percentile), and his weight was 14.4 kg
" E) D; k7 V3 z2 l# v(also >97th percentile). The observed yearly growth
4 T9 @3 K, N5 D% b3 ~velocity was 30 cm (12 inches). The examination of0 |; n6 @3 B9 \/ ~
the neck revealed no thyroid enlargement.
$ J3 j! W) J: FThe genitourinary examination was remarkable for V- M) y4 \0 d% M) ^) D( c
enlargement of the penis, with a stretched length of2 p$ T* f, d0 x. p) R& L
8 cm and a width of 2 cm. The glans penis was very well
. [9 m! C1 ]) Z6 b6 T+ \developed. The pubic hair was Tanner II, mostly around! [, P1 q. Z1 y/ N+ K4 R
540
! V/ E7 O I2 G3 z1 ]5 I* R) t5 ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 u6 f* v2 a; t+ x* O pthe base of the phallus and was dark and curled. The
: E8 s, ]* w0 [, U+ \' ^8 V8 S5 c9 _testicular volume was prepubertal at 2 mL each.
+ f5 R* c* s. I* bThe skin was moist and smooth and somewhat
' U. M) E$ p; R5 x* poily. No axillary hair was noted. There were no
) ^: i3 m! m& _+ O1 v s5 y Wabnormal skin pigmentations or café-au-lait spots.
8 R3 R: @4 c* w; t' U4 PNeurologic evaluation showed deep tendon reflex 2+5 D: o2 G: p- _/ B( j) v
bilateral and symmetrical. There was no suggestion$ @4 j( V% G% T0 a. M& n, X
of papilledema.
( W! A0 H4 o; H w& GLaboratory Evaluation
# t, ~9 b0 w$ `) ZThe bone age was consistent with 28 months by, ~3 S/ n$ O" h, V5 a
using the standard of Greulich and Pyle at a chrono-/ e/ B8 v) h0 P
logic age of 16 months (advanced).5 Chromosomal n6 M& q# r% w/ q, W
karyotype was 46XY. The thyroid function test
) i" ]2 f' r J0 w& v6 @! c/ D5 |. }showed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ d2 F- ` b0 g* Q/ b. S2 Rlating hormone level was 1.3 µIU/mL (both normal).
, c1 f# g% y# N) o7 V1 nThe concentrations of serum electrolytes, blood
7 Y# Z. Z y1 A3 _4 e4 Q) H) Rurea nitrogen, creatinine, and calcium all were
7 K0 `5 w0 L3 i- Xwithin normal range for his age. The concentration
/ ^* n+ [3 s+ G* T" ~of serum 17-hydroxyprogesterone was 16 ng/dL6 Y. k: O5 n0 s6 u9 w0 i( Y4 x
(normal, 3 to 90 ng/dL), androstenedione was 20& o% i, S2 Q! s( k
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* u8 _+ `9 f" H1 j @
terone was 38 ng/dL (normal, 50 to 760 ng/dL),) P" [# E- u* e
desoxycorticosterone was 4.3 ng/dL (normal, 7 to. |' J' ^, u2 @& o2 P. k' u. N
49ng/dL), 11-desoxycortisol (specific compound S)
1 O, I1 ^% x g* pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 _- x( {; U/ ?# T3 ]tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# u2 V# ?) Y: l0 c4 S$ F4 ]' E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 _. Q7 ?& G/ E7 eand β-human chorionic gonadotropin was less than. [7 s( ]9 ]* n; s6 `* _ Z
5 mIU/mL (normal <5 mIU/mL). Serum follicular- n/ u4 E- P* C2 J
stimulating hormone and leuteinizing hormone2 ?: f& X' E, X% e" U) \: e
concentrations were less than 0.05 mIU/mL
) c" h* }+ V* F+ @! B+ x, U" |) t; ], r(prepubertal).
- _5 s) a. V" I7 n" O/ w, U6 WThe parents were notified about the laboratory3 e! R8 F8 k( O3 p/ m; R
results and were informed that all of the tests were) L' L4 }! b- b' Q5 x
normal except the testosterone level was high. The! H1 ], q2 F8 Q# |8 c5 }% @5 ?
follow-up visit was arranged within a few weeks to
' a. ~* j; _# O w) f7 `1 m& Eobtain testicular and abdominal sonograms; how-
1 H; m5 x& x$ |" }+ m7 u: Lever, the family did not return for 4 months.
# i! n% K, k$ T% k( B: OPhysical examination at this time revealed that the
- s( {& l( U- ?0 G \/ z; B/ v# v4 ~child had grown 2.5 cm in 4 months and had gained
2 r+ F6 S7 q5 X3 K5 G2 kg of weight. Physical examination remained
: l/ N8 W# S0 u j* t; L7 Q3 a, Aunchanged. Surprisingly, the pubic hair almost com-
' C- f% S' b3 j! t! ]& J( Mpletely disappeared except for a few vellous hairs at0 t7 Z" ^9 y9 i
the base of the phallus. Testicular volume was still 29 t, b; k5 t2 E7 f: ^
mL, and the size of the penis remained unchanged./ T* P! {' n9 |& D3 |8 y
The mother also said that the boy was no longer hav-
8 I8 a. E8 b" x/ V% V/ U* C3 Hing frequent erections., ]8 P% ]$ ]0 B# s: V( h" @
Both parents were again questioned about use of, C6 G9 g) R6 h0 U& I
any ointment/creams that they may have applied to) I. z5 H3 M6 M& u1 q" H$ E
the child’s skin. This time the father admitted the
3 |. \ C8 h' ~Topical Testosterone Exposure / Bhowmick et al 5413 v1 a- }5 i7 [& \: Z4 b
use of testosterone gel twice daily that he was apply-
1 q8 Y- ?% Y4 i- ^ing over his own shoulders, chest, and back area for- C$ J. a, X! @
a year. The father also revealed he was embarrassed
+ f) \1 X" c4 N9 W Kto disclose that he was using a testosterone gel pre-
2 J2 ~! M+ X$ A! @scribed by his family physician for decreased libido3 P) F9 X% S0 i# n7 Y
secondary to depression.
, t* u8 s9 X' h2 k7 ]6 [The child slept in the same bed with parents.( p4 _/ w) O+ _. C
The father would hug the baby and hold him on his
) V: l! p7 T+ schest for a considerable period of time, causing sig-
. i# Q2 E/ B& Znificant bare skin contact between baby and father.1 F' i3 d* I `+ k/ V+ u3 G: |
The father also admitted that after the phone call,$ B8 J1 g, I O, E# I
when he learned the testosterone level in the baby
5 S$ P8 z4 H0 @" V0 b. J6 Fwas high, he then read the product information
: _4 m: z, H3 K3 w1 r8 {packet and concluded that it was most likely the rea-
7 U0 E" t/ W0 lson for the child’s virilization. At that time, they
+ H1 u5 C) G4 t4 Ddecided to put the baby in a separate bed, and the7 h# O6 ]: O" t) r/ u
father was not hugging him with bare skin and had
! I8 |+ e- P: a: nbeen using protective clothing. A repeat testosterone
8 C/ Y) k3 Y* btest was ordered, but the family did not go to the% z1 g! T# p) ~+ | R$ p" W( [
laboratory to obtain the test.
" y; Q1 r. J) W# G( UDiscussion
2 u+ h* r, q# O/ pPrecocious puberty in boys is defined as secondary4 @0 X, ~( \5 w7 V4 A
sexual development before 9 years of age.1,4& E; O0 D' M" ^! T, U
Precocious puberty is termed as central (true) when% A0 L- A3 x7 ] D( c$ \
it is caused by the premature activation of hypo-) W4 K3 D z, M4 S- H( r
thalamic pituitary gonadal axis. CPP is more com-
) l0 ~' {, e v/ [6 s' q$ a) @/ e: Kmon in girls than in boys.1,3 Most boys with CPP' c% \; J' p$ \
may have a central nervous system lesion that is. f1 I* Q& l5 O; w4 g% [
responsible for the early activation of the hypothal-
( a0 f% P7 u: f5 A% T& zamic pituitary gonadal axis.1-3 Thus, greater empha-
6 A1 e0 |3 h0 w/ K$ wsis has been given to neuroradiologic imaging in
# f- a# L7 L: j% C; ~boys with precocious puberty. In addition to viril-$ f& \3 @ w6 B: a$ }
ization, the clinical hallmark of CPP is the symmet-
# O2 J! |9 }7 e0 A brical testicular growth secondary to stimulation by
$ H, q9 R6 b$ T3 egonadotropins.1,34 r5 _0 o1 G, A) V' F, J& C7 I* N
Gonadotropin-independent peripheral preco-
# y# a" N. W# R; y. A, I% Mcious puberty in boys also results from inappropriate8 X! x) I/ W5 H5 W
androgenic stimulation from either endogenous or2 x% L* ^3 g5 S
exogenous sources, nonpituitary gonadotropin stim-& p' ]* w7 h6 A. F/ c4 w8 t
ulation, and rare activating mutations.3 Virilizing
, o0 J8 V5 j8 ~; D* acongenital adrenal hyperplasia producing excessive) W+ D; Y& {+ |3 p
adrenal androgens is a common cause of precocious0 X4 s! { b6 ~3 R4 W r5 q
puberty in boys.3,4
8 [5 B1 r1 T# ]# q6 @/ fThe most common form of congenital adrenal
1 F1 P" [7 ?7 [5 c Chyperplasia is the 21-hydroxylase enzyme deficiency.
6 `* `) H, E: `7 gThe 11-β hydroxylase deficiency may also result in
0 o& s4 ]' K8 t ]7 c( i1 l3 Vexcessive adrenal androgen production, and rarely,* H3 [( o$ ?* r+ b
an adrenal tumor may also cause adrenal androgen# H2 k% {5 }% x1 K' Z
excess.1,3# U& t/ K2 f& e+ _! P! z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. k: e* Y* e& Q: d% R
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ F2 R _) t& A5 l8 m. ^( q O
A unique entity of male-limited gonadotropin-
, q7 J9 _0 ^" [independent precocious puberty, which is also known Q7 }1 f% p0 Z5 z6 Z1 H
as testotoxicosis, may cause precocious puberty at a
" R3 r: ?& o& v* ]. {( _* Uvery young age. The physical findings in these boys" P: J. j* a0 M
with this disorder are full pubertal development,
+ N* x0 O) {, O" ^7 uincluding bilateral testicular growth, similar to boys. o7 p1 E( Z) c: e+ I4 x& `
with CPP. The gonadotropin levels in this disorder' R/ L# k) |( a' @
are suppressed to prepubertal levels and do not show' ~3 B0 Q) u* u6 n6 C0 ]' U
pubertal response of gonadotropin after gonadotropin-0 Y# g3 e8 x7 ~% h5 }' c
releasing hormone stimulation. This is a sex-linked6 n; B2 w0 Y1 s ]$ r
autosomal dominant disorder that affects only& k3 s0 {" O( P% f" z
males; therefore, other male members of the family
7 m& z4 K! C4 g" Dmay have similar precocious puberty.3
' {* Q1 k* q: b9 N! {! nIn our patient, physical examination was incon-) K8 K: e- c) B, `$ z" j: B
sistent with true precocious puberty since his testi-+ f) g, _- C8 T& A: V# @# _
cles were prepubertal in size. However, testotoxicosis3 k, w- A# n7 }% z% V2 I
was in the differential diagnosis because his father
0 H! F, y# ?3 m7 s) Xstarted puberty somewhat early, and occasionally,. m& L+ R F# y+ u
testicular enlargement is not that evident in the3 `: H" c, [# W: e u& N
beginning of this process.1 In the absence of a neg-
6 i% R( H8 ?3 W5 K0 X( M6 P% t& bative initial history of androgen exposure, our* R# o3 V. j8 }
biggest concern was virilizing adrenal hyperplasia,
" f0 j1 I3 b' yeither 21-hydroxylase deficiency or 11-β hydroxylase, T' c" H. u: r! h
deficiency. Those diagnoses were excluded by find-
- `- n) I! o# F% Y- B0 s6 uing the normal level of adrenal steroids., B3 q( G) s8 ^6 M+ N
The diagnosis of exogenous androgens was strongly
7 b+ X% x7 h, V2 msuspected in a follow-up visit after 4 months because
0 F8 w( |+ w$ S/ G2 w4 e8 ?the physical examination revealed the complete disap-
) D; c, P: k6 z) M" c% Qpearance of pubic hair, normal growth velocity, and
( o' [: m8 {1 n2 F" X/ Pdecreased erections. The father admitted using a testos-' c3 V! f) q* z
terone gel, which he concealed at first visit. He was
" D! j" S7 a* a3 Iusing it rather frequently, twice a day. The Physicians’
" j# s6 V! j% {- X3 PDesk Reference, or package insert of this product, gel or
: h1 y$ y8 s2 tcream, cautions about dermal testosterone transfer to7 y6 h. m# \$ q( e/ _2 |
unprotected females through direct skin exposure.
" A1 w, ?$ ^% D' a3 u: wSerum testosterone level was found to be 2 times the
5 @, t0 `4 U" i3 Q% S0 Jbaseline value in those females who were exposed to2 ^% k3 G1 y J* a- T
even 15 minutes of direct skin contact with their male
. X" a# \5 ?- V9 r# N) ^( Upartners.6 However, when a shirt covered the applica-( |+ v* f' R+ U- ?# @3 T* j
tion site, this testosterone transfer was prevented.
3 X8 ~, b, K" L+ Z9 \4 C* K$ @! MOur patient’s testosterone level was 60 ng/mL,9 }$ M% f8 T; l" }
which was clearly high. Some studies suggest that
K' z8 a, h4 R8 Tdermal conversion of testosterone to dihydrotestos-/ \) }# Y& k7 ]
terone, which is a more potent metabolite, is more
7 i" s- y g" B& U: g! S' [active in young children exposed to testosterone
. s! ~3 {! E' c6 X" texogenously7; however, we did not measure a dihy-! ~" [# y% H2 b$ T9 G
drotestosterone level in our patient. In addition to; Z; q. @+ W, j8 z
virilization, exposure to exogenous testosterone in+ H) `$ W! w6 h1 k& z
children results in an increase in growth velocity and7 [" [- d. H0 `8 P# \+ @
advanced bone age, as seen in our patient.
1 J; U6 f3 ~2 }9 ~' GThe long-term effect of androgen exposure during
* q8 u! g; d G8 N2 u( b/ rearly childhood on pubertal development and final; d9 ]6 C |3 x* N( [( Z
adult height are not fully known and always remain
0 ]/ v' e/ d5 L/ @3 Ha concern. Children treated with short-term testos-' T6 y& N$ X/ i4 a8 i% z! v& ]
terone injection or topical androgen may exhibit some2 Z8 ~5 O& R# P
acceleration of the skeletal maturation; however, after+ A; ^, O4 j: p' e, W
cessation of treatment, the rate of bone maturation9 y0 t9 [0 P6 _, P# t! X' p0 D" _
decelerates and gradually returns to normal.8,9% c: E- D u$ x& P. O7 S; [; P5 f
There are conflicting reports and controversy4 I# c9 v( y5 W1 E+ A( i' [1 L( \
over the effect of early androgen exposure on adult/ W/ ^4 Q: b6 ]
penile length.10,11 Some reports suggest subnormal2 z3 q; |# |3 |$ R
adult penile length, apparently because of downreg-- A, @3 c q% r8 i& E: l
ulation of androgen receptor number.10,12 However,
& t( k! }" R0 QSutherland et al13 did not find a correlation between
# I4 v4 A$ [) S$ G% n# m0 B$ kchildhood testosterone exposure and reduced adult2 \4 |! y+ Y3 c* b1 `: b* }0 P
penile length in clinical studies." Y0 s1 ~" q0 e6 I
Nonetheless, we do not believe our patient is
1 J, e. ~0 Y {! O! F4 Q7 ogoing to experience any of the untoward effects from2 W2 s: ]8 Q" d! x9 p5 M
testosterone exposure as mentioned earlier because
$ c/ f+ ]& v; E X+ ]the exposure was not for a prolonged period of time.
4 X# |% q+ @! ~3 } I' y6 d! {Although the bone age was advanced at the time of) o, p- W8 p( j% y1 _, z+ W
diagnosis, the child had a normal growth velocity at4 p. P$ a" _* B/ x0 C2 Y
the follow-up visit. It is hoped that his final adult
* Q" @7 o5 R5 n& W* Wheight will not be affected.0 r: ]( p2 G9 y; S
Although rarely reported, the widespread avail-* a* _( \! K" h0 z2 o
ability of androgen products in our society may
$ L5 Z% y4 {( K- Y' `1 ?. I! windeed cause more virilization in male or female5 O5 O7 d/ c7 S
children than one would realize. Exposure to andro-
6 J! v" M) ]& [gen products must be considered and specific ques-& s0 p! [/ p; e: C" D8 |, U, ?
tioning about the use of a testosterone product or# Z( P& s5 P" m( |. k0 J
gel should be asked of the family members during) y& d- f$ a0 |
the evaluation of any children who present with vir-1 H* _5 c6 l/ w, @) _
ilization or peripheral precocious puberty. The diag-' z5 M& V8 `7 h5 m- a7 ]% J2 ] C
nosis can be established by just a few tests and by
0 u7 j1 \: {8 R) vappropriate history. The inability to obtain such a
. v: L4 y. p r1 E2 a8 _history, or failure to ask the specific questions, may
3 b( b9 @5 p/ @, \. b" oresult in extensive, unnecessary, and expensive
; F( Y+ ~& B- V# B9 O# vinvestigation. The primary care physician should be0 Z. p4 d! B0 Y3 O7 t
aware of this fact, because most of these children
& Y n' S5 |9 j6 Ymay initially present in their practice. The Physicians’
5 L: z3 ~3 ~0 SDesk Reference and package insert should also put a
( {6 [8 w- _9 r) n3 Qwarning about the virilizing effect on a male or# `9 r- i& y9 L2 Q6 R$ l
female child who might come in contact with some-
. y, {* _, k% {9 m1 Yone using any of these products.
7 b4 e- x! V$ c" [! g; g. ZReferences3 ]' @( E! P& X4 i. O( J& D
1. Styne DM. The testes: disorder of sexual differentiation8 c! @9 Z" Q r0 Z T7 G9 `
and puberty in the male. In: Sperling MA, ed. Pediatric! u; s8 j) @9 a1 Q2 O
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ C2 ~- q! {5 g2002: 565-628.
. [& A: c! ?2 X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
9 q, f( ]3 q' g* e; m1 g) `puberty in children with tumours of the suprasellar pineal |
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