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Sexual Precocity in a 16-Month-Old5 V9 k% z" k3 X% a
Boy Induced by Indirect Topical
4 t* L5 C' }/ H. @# h' t: H) NExposure to Testosterone0 y1 x2 T* Y0 `. M' Z9 g/ g# s
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& _8 U' T1 `2 A+ S! |/ kand Kenneth R. Rettig, MD1
3 n9 g) i2 m7 W& z$ vClinical Pediatrics
/ H0 H- R/ f4 p+ s, M( B6 |Volume 46 Number 65 h7 _ ?5 e% g
July 2007 540-543 M8 t* y7 \: q. x) d
© 2007 Sage Publications
4 h: M# [% U k$ E8 ^10.1177/0009922806296651! v" V# y3 Q9 {- B, e
http://clp.sagepub.com
& T7 P) \- V/ m8 ^% zhosted at) G# R, N" j' ?% _1 Z' a+ I: P- k
http://online.sagepub.com
! \+ ~ N: @0 u& oPrecocious puberty in boys, central or peripheral,
( o0 [! h8 k* t7 H8 [is a significant concern for physicians. Central. X0 W+ d; z. Z5 \' X1 k# M. x
precocious puberty (CPP), which is mediated, O( X* }. x7 l' ~, h* @* q
through the hypothalamic pituitary gonadal axis, has
& R! W2 A) l' X! f0 pa higher incidence of organic central nervous system, _' T9 r, T' |( d
lesions in boys.1,2 Virilization in boys, as manifested
, I h, d8 P( }' P6 [7 Bby enlargement of the penis, development of pubic
1 |5 G( Q9 }: e* z- H* z; X& U( Ohair, and facial acne without enlargement of testi-; s) K$ s9 w& @ r& G' k2 P
cles, suggests peripheral or pseudopuberty.1-3 We
' c1 y3 F$ `: y( Dreport a 16-month-old boy who presented with the* v7 {/ ~( b* I, B; [- n
enlargement of the phallus and pubic hair develop-
2 r5 O" \7 u; ^" K& Iment without testicular enlargement, which was due0 e8 z+ l+ ]8 Y
to the unintentional exposure to androgen gel used by
( P3 u! x/ \" xthe father. The family initially concealed this infor-
) \" ?6 V# I7 L' K7 y. umation, resulting in an extensive work-up for this
8 l4 L0 f" w) ~( ~child. Given the widespread and easy availability of9 L8 o' m' K( e( y& J
testosterone gel and cream, we believe this is proba-
# _. f4 l1 M4 G- X& O2 Obly more common than the rare case report in the
$ j5 T( @1 S: D0 `; B( Y9 @$ }" Lliterature.48 i% x4 p' ?1 h4 S- E
Patient Report
6 h! l9 `( \$ aA 16-month-old white child was referred to the" |5 K( c) l# d+ U
endocrine clinic by his pediatrician with the concern+ L. y/ t# z: J) y% B
of early sexual development. His mother noticed
# r. ~7 h: j: e. vlight colored pubic hair development when he was& Q, `4 n6 w! e: ~
From the 1Division of Pediatric Endocrinology, 2University of. J9 [4 @0 l' H/ X# m
South Alabama Medical Center, Mobile, Alabama.
' e8 a! G1 K4 WAddress correspondence to: Samar K. Bhowmick, MD, FACE,
7 s* a! {; q7 B$ j' d5 Q6 eProfessor of Pediatrics, University of South Alabama, College of
" ^" ]; W4 Q3 U' e# ZMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' O! g; @( Z2 D# c6 P6 G& |
e-mail: [email protected].
2 K& y X# r% p( \about 6 to 7 months old, which progressively became5 J5 z& q- F/ y" {5 f) d) m
darker. She was also concerned about the enlarge-
9 L/ h% ~2 E2 H6 f4 [7 ~ment of his penis and frequent erections. The child8 r1 E9 K, W4 j4 p! N) a
was the product of a full-term normal delivery, with: P# i4 Y- b" a# b
a birth weight of 7 lb 14 oz, and birth length of
: V4 \' L8 P7 o/ l9 w( W20 inches. He was breast-fed throughout the first year0 @, X0 i1 `% A5 Q# \* m
of life and was still receiving breast milk along with! S" w! V& X- U* G6 U$ j
solid food. He had no hospitalizations or surgery,; a( A; v: E/ ]- g
and his psychosocial and psychomotor development. z% g' T2 z( A3 U# X) |, I4 b% A* y; L
was age appropriate.7 y6 u( f7 R, F4 R/ J6 K3 S1 \2 f% f$ _
The family history was remarkable for the father,
3 }9 _8 Z% B# p6 xwho was diagnosed with hypothyroidism at age 16,
$ x1 a$ D5 R( W4 r {) ^5 k" Awhich was treated with thyroxine. The father’s; x) d5 {7 J- {& |1 i9 g0 c1 Q/ }+ ~) A
height was 6 feet, and he went through a somewhat
9 C+ l4 }% v& t1 [- ~( p# Z$ Searly puberty and had stopped growing by age 14.
! y6 Z% A6 M/ B7 iThe father denied taking any other medication. The
' J5 p, n3 ?) V; E% l, r R) ~child’s mother was in good health. Her menarche
' Q9 q0 y( p/ Awas at 11 years of age, and her height was at 5 feet# Z7 |3 Q* T1 ~7 Q# g4 H
5 inches. There was no other family history of pre-+ B# k3 U$ ^& `8 E8 i
cocious sexual development in the first-degree rela-+ j' Q3 {, c6 r
tives. There were no siblings.3 X/ m* j1 R# U3 \6 q" L- n
Physical Examination
8 e8 w4 u4 x# c$ xThe physical examination revealed a very active,7 o, W2 }2 ]8 H% t& [
playful, and healthy boy. The vital signs documented. B' R9 ] c7 a" L( v
a blood pressure of 85/50 mm Hg, his length was
2 t4 x$ d6 _, B. K4 Y0 Z A E90 cm (>97th percentile), and his weight was 14.4 kg
. c! K' ^- {. f7 F' D(also >97th percentile). The observed yearly growth4 `$ o% l3 B' u
velocity was 30 cm (12 inches). The examination of
1 V% N: v0 ~* v8 nthe neck revealed no thyroid enlargement.
" K' y- ?2 g) k. M/ H( \# fThe genitourinary examination was remarkable for8 f1 W9 g W) i: W: k [7 d
enlargement of the penis, with a stretched length of8 v- S# Q( F+ Y# E* i' r( y
8 cm and a width of 2 cm. The glans penis was very well: O( g0 M; }- m7 g
developed. The pubic hair was Tanner II, mostly around' q; |. G- P2 h7 S, \1 V( a
540
/ g: s* G) W( ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 W3 x# r0 p( j' c( K: J! k
the base of the phallus and was dark and curled. The" x$ m& i6 l2 S8 W# r% l) R
testicular volume was prepubertal at 2 mL each.
4 W8 y6 A5 N2 J6 q! [3 T" _The skin was moist and smooth and somewhat
) u) d# h1 y7 A& H4 S" Aoily. No axillary hair was noted. There were no
6 V! z {, b8 p+ c; ^ i n0 gabnormal skin pigmentations or café-au-lait spots.
0 G* P0 a* @) j$ a' f5 z( Y6 [1 T) bNeurologic evaluation showed deep tendon reflex 2+
0 s: F9 [9 ^ n( g! t# w* m0 Abilateral and symmetrical. There was no suggestion9 o/ h# l$ w8 F6 C
of papilledema.
; r2 b" P8 a) |$ RLaboratory Evaluation
7 j# v0 e, K1 ]/ C3 D9 DThe bone age was consistent with 28 months by! C/ x+ K5 T8 t9 O1 t( i3 t
using the standard of Greulich and Pyle at a chrono-
# t* l( k8 R) S( {9 }; W9 w/ Flogic age of 16 months (advanced).5 Chromosomal
x8 R1 a( A) v1 e$ ?karyotype was 46XY. The thyroid function test
' U6 l) l0 ^: n2 v* Rshowed a free T4 of 1.69 ng/dL, and thyroid stimu-- }6 g. F$ P, ~+ P( i8 n. ?
lating hormone level was 1.3 µIU/mL (both normal).' J! q" A# w' w* m! b$ n
The concentrations of serum electrolytes, blood
$ T- Q0 v) f- L Iurea nitrogen, creatinine, and calcium all were. {" r5 p5 s9 u Q$ ^/ S
within normal range for his age. The concentration
- ~5 w0 K7 L1 |. ]* ]9 tof serum 17-hydroxyprogesterone was 16 ng/dL6 O. J; n) T; T1 P5 G! F
(normal, 3 to 90 ng/dL), androstenedione was 20$ R; y! _# e* a
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ w4 }! w* |8 H# N% oterone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 R$ T2 a9 W" h6 V. i0 p2 V) Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
! Y N8 A: Y5 L6 _" _5 Q49ng/dL), 11-desoxycortisol (specific compound S)/ }0 C' {2 |# G6 y: X$ e3 _0 @
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 O% v, B4 }$ Y8 m6 U- D' r% p
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
+ `' v: s: z/ U4 Z) r( gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% ^% h Q; f! Y! G1 j [) M {and β-human chorionic gonadotropin was less than
! h2 @, V9 \! g, u4 n5 mIU/mL (normal <5 mIU/mL). Serum follicular5 h: S4 b+ ^9 _: A, C4 ~3 L* @
stimulating hormone and leuteinizing hormone
9 S! r, o2 k Q. Oconcentrations were less than 0.05 mIU/mL* j, Q0 n" B+ W
(prepubertal).
! y$ f0 x, T: S4 u& d) H( A/ e ~The parents were notified about the laboratory0 F4 A) @3 s8 u+ O
results and were informed that all of the tests were
$ X) n+ ~. e) i$ {! rnormal except the testosterone level was high. The
( f& ~6 T% o; H9 ofollow-up visit was arranged within a few weeks to8 N* {) d$ B0 E# G
obtain testicular and abdominal sonograms; how-$ ~/ Y5 Y w( V+ g# U
ever, the family did not return for 4 months.
8 [4 y* ~7 R8 ]0 f) i9 o) `Physical examination at this time revealed that the. ]! O' q6 ^4 T p& e4 P$ n$ |
child had grown 2.5 cm in 4 months and had gained y4 j- n) a4 p3 [' X# _8 p# [8 ^; E
2 kg of weight. Physical examination remained
3 r" d& ]/ i' }9 T$ Nunchanged. Surprisingly, the pubic hair almost com-
8 D& M; N3 L4 a' z+ Fpletely disappeared except for a few vellous hairs at
0 ^" B! h, h4 O% ^( B% l" ^4 Lthe base of the phallus. Testicular volume was still 2
' F6 v" ~0 J/ c3 WmL, and the size of the penis remained unchanged.' [3 L) e, O2 q' ]
The mother also said that the boy was no longer hav-# \) J+ o, ]" ^+ s# B: f
ing frequent erections.
+ o+ X% q/ a& a. |Both parents were again questioned about use of4 u5 U4 G- W6 a- v: b; H' Z4 k% f
any ointment/creams that they may have applied to
2 D1 ~ x' X- I0 }+ x& \the child’s skin. This time the father admitted the) f: n1 Q; a9 { n. e6 B
Topical Testosterone Exposure / Bhowmick et al 5418 z! w+ f2 R& f: F3 W: V
use of testosterone gel twice daily that he was apply-
/ l! h( G8 z0 b U2 p* |+ s |8 ying over his own shoulders, chest, and back area for
' `5 O8 l$ R$ Ka year. The father also revealed he was embarrassed
5 E& o7 ?: v% q6 Pto disclose that he was using a testosterone gel pre-
, ?" ^; @+ q9 A/ J. ^" ascribed by his family physician for decreased libido
" B @! _ B2 Bsecondary to depression.
2 O, C6 S' r0 W" U# pThe child slept in the same bed with parents.0 u; A3 g3 B5 C# A$ I2 ?0 x) c2 N
The father would hug the baby and hold him on his* t# h$ C$ i: D' D: d* \
chest for a considerable period of time, causing sig-! L# @+ s) e9 M
nificant bare skin contact between baby and father.
5 Z/ y2 }7 P9 f( CThe father also admitted that after the phone call,$ V% s. u* J2 x1 ~1 B
when he learned the testosterone level in the baby
8 N, N6 ~2 J5 t5 w' }0 x% Swas high, he then read the product information
4 E7 V3 u$ Q- K- z5 O( Gpacket and concluded that it was most likely the rea-
: a* L( R# ^- k M' hson for the child’s virilization. At that time, they
3 J/ I6 e# N# H/ |decided to put the baby in a separate bed, and the
: O! Z6 M* P" Mfather was not hugging him with bare skin and had
( C! g$ P8 M4 e% q, B$ U% U* Ibeen using protective clothing. A repeat testosterone
& k0 y/ S' {9 T- ltest was ordered, but the family did not go to the
d. }; N! J! ]" F ylaboratory to obtain the test.1 R3 S$ `3 |! A: M
Discussion
& E2 c' L8 s& y# A. CPrecocious puberty in boys is defined as secondary
6 o# j4 }$ r2 c6 Jsexual development before 9 years of age.1,41 k5 }7 i5 h1 f1 f" d
Precocious puberty is termed as central (true) when
9 R1 o+ g" f7 V0 Q" J {7 Mit is caused by the premature activation of hypo-/ {# r+ d: w+ \% W A
thalamic pituitary gonadal axis. CPP is more com-& V4 _0 M: n- y7 W
mon in girls than in boys.1,3 Most boys with CPP
$ S$ ]% j, ?. |/ E6 b5 mmay have a central nervous system lesion that is5 u2 a7 I$ d+ J2 K+ t4 B1 m9 b
responsible for the early activation of the hypothal-6 ~- c0 z6 R: N; k
amic pituitary gonadal axis.1-3 Thus, greater empha-
% A0 x0 W' D, P* isis has been given to neuroradiologic imaging in6 A7 W3 a& o/ ?' I
boys with precocious puberty. In addition to viril-7 ?4 w: d/ V* }. s6 f0 K
ization, the clinical hallmark of CPP is the symmet-+ z& B9 e( L# a J. ~$ C3 i- [
rical testicular growth secondary to stimulation by
; o5 M' `* v/ N! d, @, J5 j% Lgonadotropins.1,3' {$ d e; T; p M: I" ~' q) S8 D" F
Gonadotropin-independent peripheral preco-- K7 j k c, \. w
cious puberty in boys also results from inappropriate7 X! i+ N1 D t G2 I9 W
androgenic stimulation from either endogenous or) {. R/ [9 ?* |! q5 i4 Z4 ^
exogenous sources, nonpituitary gonadotropin stim-4 ?2 t# J6 {7 h% h% b2 w* q
ulation, and rare activating mutations.3 Virilizing
; d1 |% I5 R2 acongenital adrenal hyperplasia producing excessive# v$ v+ u1 H# ~7 Y& Z
adrenal androgens is a common cause of precocious
+ \2 U. f; ?8 a+ I' W; w; s, a) Zpuberty in boys.3,4
6 B7 ^3 W) m* jThe most common form of congenital adrenal9 x. Y( v0 d+ b2 L
hyperplasia is the 21-hydroxylase enzyme deficiency.
9 P. K) K0 I: q$ DThe 11-β hydroxylase deficiency may also result in
$ k4 ?) I" p' i- ~, Bexcessive adrenal androgen production, and rarely,8 u& h! {1 E6 g0 X" B2 P; R+ U
an adrenal tumor may also cause adrenal androgen0 L+ `- N5 n( F: y0 G/ d6 Y- H
excess.1,3
/ k! b4 Y! T- S) f; `" F( Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 g: b. R6 m& S E1 R
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
# h: M& `, G% L w6 P! SA unique entity of male-limited gonadotropin-
/ d; `; l7 n& ]: j! |independent precocious puberty, which is also known
; ?; a" D V5 \. K% Pas testotoxicosis, may cause precocious puberty at a& T! {4 T2 p% i% q" L
very young age. The physical findings in these boys
. w: S! [8 A _1 wwith this disorder are full pubertal development,! H0 j0 H% R r! W* n3 B$ X* y, I
including bilateral testicular growth, similar to boys. ~; G3 }7 z* L) l' V3 ]; d- \
with CPP. The gonadotropin levels in this disorder8 R, e( r" t* G- `0 y6 o) F. C
are suppressed to prepubertal levels and do not show
' k8 D7 t" M5 O3 Fpubertal response of gonadotropin after gonadotropin-
! Y! C+ w; Q1 ~( Hreleasing hormone stimulation. This is a sex-linked0 f' l- g& m- P. r1 a- x, }$ r% e
autosomal dominant disorder that affects only
+ K# [" a3 f2 I* j0 \6 Lmales; therefore, other male members of the family
9 c, @' Y9 N8 T2 m2 xmay have similar precocious puberty.3
0 \. z3 Q) u. Q. Z8 Y5 hIn our patient, physical examination was incon-6 n2 @7 X D( N s4 `6 T
sistent with true precocious puberty since his testi-
' u# R4 E/ _% N! a1 ]1 o. Scles were prepubertal in size. However, testotoxicosis Z( S7 V8 s5 a# K! h
was in the differential diagnosis because his father
& V; p W: [0 N6 o1 s Mstarted puberty somewhat early, and occasionally,
7 V; T L0 m, q. H6 P ~% }testicular enlargement is not that evident in the
# S9 \. e3 p' E- [8 K* x0 zbeginning of this process.1 In the absence of a neg-
. `0 z0 L- p1 P& m7 D% Pative initial history of androgen exposure, our4 e: q# E& I1 k/ g0 Z7 q
biggest concern was virilizing adrenal hyperplasia,
: ~$ ?" h$ H9 D1 q4 ^9 d, \either 21-hydroxylase deficiency or 11-β hydroxylase3 `/ z4 A& b. [( F
deficiency. Those diagnoses were excluded by find-
8 K3 R3 w7 d/ O! Zing the normal level of adrenal steroids.
$ e& w7 _5 j% e' _4 V/ Y- uThe diagnosis of exogenous androgens was strongly; Z- t# V' b0 ?" X0 X
suspected in a follow-up visit after 4 months because
# ~( C" O! m/ I6 v7 h# U* ?the physical examination revealed the complete disap-
, g8 u0 ]8 D+ O' F |8 s" ?# g# Vpearance of pubic hair, normal growth velocity, and
g0 X/ W1 e2 l0 \& e6 wdecreased erections. The father admitted using a testos-( z! `# s p- R ]2 X* I
terone gel, which he concealed at first visit. He was
" b- o. s G S. H+ y7 Qusing it rather frequently, twice a day. The Physicians’
8 P0 M" M5 Q2 R4 T0 CDesk Reference, or package insert of this product, gel or, _( r. U! i: f5 q
cream, cautions about dermal testosterone transfer to. I. W m+ V. X
unprotected females through direct skin exposure.+ f: y" }9 o: u5 _# t9 F+ i
Serum testosterone level was found to be 2 times the
/ D& f, p) n2 A# Q$ Y9 Z5 [baseline value in those females who were exposed to
% g$ W) T5 E% y& n) y0 z2 Y* geven 15 minutes of direct skin contact with their male
* r0 V- I `/ {7 R6 Lpartners.6 However, when a shirt covered the applica-* V; U" A6 ?$ N: @! O
tion site, this testosterone transfer was prevented.
# ~' u. H) S' _Our patient’s testosterone level was 60 ng/mL,
2 j L- m, D7 J- K3 G% Lwhich was clearly high. Some studies suggest that2 Q K0 O, N' z; E( u( p
dermal conversion of testosterone to dihydrotestos-
% [1 n- L/ V+ G; C! u. x2 Y/ Tterone, which is a more potent metabolite, is more7 F D$ u/ L f# H% X( q' h
active in young children exposed to testosterone
7 w6 N* ?$ f Zexogenously7; however, we did not measure a dihy-
6 z: w! F8 m% W" edrotestosterone level in our patient. In addition to+ R4 V9 D. B% x
virilization, exposure to exogenous testosterone in5 c( i' q: _& _. I$ U0 L- z& C
children results in an increase in growth velocity and
D( N8 p! g, K- O) padvanced bone age, as seen in our patient.
7 V9 P2 I( j0 m j9 W1 p* B) nThe long-term effect of androgen exposure during2 h8 V4 m! j! p) b7 ]
early childhood on pubertal development and final1 U/ u/ _4 h8 ]# c2 N0 P& P
adult height are not fully known and always remain
- T' P7 _* g& Z9 M5 G& X$ Pa concern. Children treated with short-term testos-
! w; b3 q. x) Sterone injection or topical androgen may exhibit some& b7 t; e5 w; g7 F! a# j
acceleration of the skeletal maturation; however, after
6 d$ w* j# G+ Rcessation of treatment, the rate of bone maturation
4 l5 q: ?2 }. N3 J4 c S) ~" _decelerates and gradually returns to normal.8,97 \ v7 [9 B5 G" L6 G
There are conflicting reports and controversy
% b; m, s- u/ `$ eover the effect of early androgen exposure on adult
4 k2 c2 ]1 r2 ^8 b; @7 b; hpenile length.10,11 Some reports suggest subnormal$ C7 x9 i9 h9 M0 b
adult penile length, apparently because of downreg-
6 W/ s9 z) ?# z8 j& u4 ]7 Wulation of androgen receptor number.10,12 However,- c2 m% p! M+ J. G1 O# l
Sutherland et al13 did not find a correlation between
. q# S' ]7 A& f$ Q0 schildhood testosterone exposure and reduced adult5 n+ B* W9 [: t1 y1 Z( \! g
penile length in clinical studies.
. g `* s3 J5 O5 oNonetheless, we do not believe our patient is6 t9 ~. V( h7 D
going to experience any of the untoward effects from9 [" c8 q; {3 @. v9 g( Y# ^
testosterone exposure as mentioned earlier because4 I/ J. W) z5 q
the exposure was not for a prolonged period of time.& U* O4 D0 k- d* g0 E( {5 `3 q+ H) w
Although the bone age was advanced at the time of) @ v8 _2 z" l
diagnosis, the child had a normal growth velocity at3 c ]0 y( y( o/ D, q1 V ~
the follow-up visit. It is hoped that his final adult- }8 Y% d- X4 f: D! @) u
height will not be affected.- K. J5 h6 N' V5 j4 f
Although rarely reported, the widespread avail-
" f" F* v5 R6 |" f0 |( D0 n0 r! dability of androgen products in our society may% U/ _+ N* t6 d
indeed cause more virilization in male or female
& R5 e) b& c( n3 Hchildren than one would realize. Exposure to andro-( B+ l; `) P. X
gen products must be considered and specific ques- _( o) N- H C! Y
tioning about the use of a testosterone product or! C$ ]; I! e5 X* W
gel should be asked of the family members during' i5 q/ ~" `! Z
the evaluation of any children who present with vir-
* i$ V" Q, N ^! \6 O# K2 g# ~6 Xilization or peripheral precocious puberty. The diag-. M+ \5 [; h6 p$ E5 N; L
nosis can be established by just a few tests and by4 n5 Y) V4 e6 B3 U8 u
appropriate history. The inability to obtain such a# I9 m C, c/ q8 l
history, or failure to ask the specific questions, may
3 O0 c* B1 s2 Z4 c. Y' x* Xresult in extensive, unnecessary, and expensive& A' u8 f7 Q0 e" g+ M
investigation. The primary care physician should be( b6 l! e, c1 Z$ ?7 w: z
aware of this fact, because most of these children( }6 h" m" `* p0 C, r
may initially present in their practice. The Physicians’
5 L% B1 @6 y sDesk Reference and package insert should also put a
$ M. R( s- P, H& P* Xwarning about the virilizing effect on a male or' M% x9 P4 |5 U) D8 P$ s3 p
female child who might come in contact with some- k- F3 I) \0 b0 {) O
one using any of these products.
* ~$ Q0 x2 b d! S/ ~* o% kReferences
5 A' ]: c5 U }' Q1. Styne DM. The testes: disorder of sexual differentiation# Y. S% w; m( N- l8 t
and puberty in the male. In: Sperling MA, ed. Pediatric
]- n: K! @, x' hEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 J3 e+ p! o; @; M2002: 565-628.
8 D% I7 H' @0 }3 B: j C: {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: P2 K$ s& U9 Dpuberty in children with tumours of the suprasellar pineal |
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