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Sexual Precocity in a 16-Month-Old2 V& L% S+ Y7 Y. p: g
Boy Induced by Indirect Topical
. h& R" g1 f/ y6 J7 l* {Exposure to Testosterone
$ h4 x' j* O, b# s, QSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. i. g- r! Q" D8 n0 Wand Kenneth R. Rettig, MD1
! N. n6 o$ x8 [1 sClinical Pediatrics+ O4 J6 p) E' l- R* s* K. K/ O
Volume 46 Number 6 y6 k/ F: [' \' g$ F
July 2007 540-543
5 T2 \! v0 } Q3 W5 |' G, {© 2007 Sage Publications$ \. x, b7 ], {& k1 q
10.1177/0009922806296651" c2 Q: x3 c. x9 n3 p
http://clp.sagepub.com
& V. D/ c) W: Y' r$ Y4 j6 Vhosted at
/ o; B7 o5 U2 }0 ?7 b* V# lhttp://online.sagepub.com
8 E3 m# {2 w. H8 w7 o) L3 _4 ~Precocious puberty in boys, central or peripheral,
# _& b3 H# w$ Bis a significant concern for physicians. Central
/ A. U1 h& j1 `% P9 r4 o( x& O: yprecocious puberty (CPP), which is mediated
A% A& n# Q- E( s' m5 N, tthrough the hypothalamic pituitary gonadal axis, has
9 q# a) ?$ x- l, c3 Ca higher incidence of organic central nervous system0 R! Z9 t6 a+ z9 t
lesions in boys.1,2 Virilization in boys, as manifested
7 F6 c6 d# Q3 \( Z# K6 Fby enlargement of the penis, development of pubic1 H+ V# C. D0 w" @3 a4 a# ?3 K
hair, and facial acne without enlargement of testi-
1 Y* i4 j/ Z6 m9 m8 e' P8 Bcles, suggests peripheral or pseudopuberty.1-3 We0 J A0 W5 I; J# O
report a 16-month-old boy who presented with the
" g* x$ _9 k+ t2 J+ _! oenlargement of the phallus and pubic hair develop-
; ]7 _2 x4 l+ q" u; sment without testicular enlargement, which was due
1 D5 D+ S( S( C0 hto the unintentional exposure to androgen gel used by0 Q( l) e F8 P, x: e
the father. The family initially concealed this infor-
0 `: q# p! j0 e( C3 pmation, resulting in an extensive work-up for this( p9 B: }1 e# L8 a T3 y r% z% c
child. Given the widespread and easy availability of* x" [# y7 T `% o7 z- K& B
testosterone gel and cream, we believe this is proba-7 e4 D1 n3 p6 @# h& @
bly more common than the rare case report in the
* o6 Y) j! M& c/ gliterature.4
2 [% b1 ?' Y3 p% `* t& Z% DPatient Report
" c9 C* i; X9 U( w1 t" {A 16-month-old white child was referred to the0 u) d+ p! d& ]) ~- `' ^5 ?/ z/ x4 t
endocrine clinic by his pediatrician with the concern
* K: [% D1 n, u4 Xof early sexual development. His mother noticed5 P( B# Y% g) b A& n
light colored pubic hair development when he was
- q7 _5 A( E6 QFrom the 1Division of Pediatric Endocrinology, 2University of
& b/ O' c3 q9 o* k1 \7 ySouth Alabama Medical Center, Mobile, Alabama.
( A0 \( a+ }1 o c& [9 E; }, ?3 iAddress correspondence to: Samar K. Bhowmick, MD, FACE,) D! W8 H8 |# c3 i! y" |4 ]0 N
Professor of Pediatrics, University of South Alabama, College of" B6 \. M( U9 _& W ^1 g
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
' |( S8 M+ q9 }8 P/ ]" J E3 qe-mail: [email protected].
2 o9 C) C; S0 V" [1 t8 cabout 6 to 7 months old, which progressively became: O+ r8 @4 k0 T
darker. She was also concerned about the enlarge-
# `1 z; x P/ V% Q' P6 Ement of his penis and frequent erections. The child. C( L; s0 e/ B: x7 w+ K) y
was the product of a full-term normal delivery, with1 d9 P( s- B) J! ?/ g
a birth weight of 7 lb 14 oz, and birth length of- h% V& W4 f$ c6 o
20 inches. He was breast-fed throughout the first year4 N0 a. t: r8 a; r( ?/ ~4 q8 ~
of life and was still receiving breast milk along with
) m1 p+ ` c3 O* msolid food. He had no hospitalizations or surgery,0 Z7 k { V: ?9 l( M/ G# g" H
and his psychosocial and psychomotor development: S' `& ]7 A' T; D
was age appropriate.9 S; Q" Q. J3 I m
The family history was remarkable for the father,
' \% i6 X- }) K/ Y' \who was diagnosed with hypothyroidism at age 16,3 n9 A) m7 T' w6 _3 X
which was treated with thyroxine. The father’s
1 u+ x; x: ], x& V7 Uheight was 6 feet, and he went through a somewhat8 e6 c/ [8 Y9 d4 M- v2 F
early puberty and had stopped growing by age 14.3 n. w. J' w5 I0 l$ l
The father denied taking any other medication. The
2 I T5 m$ F) M5 A' kchild’s mother was in good health. Her menarche* r1 X! `9 e5 t
was at 11 years of age, and her height was at 5 feet$ m) Z6 J9 B$ W; Y2 ~8 W2 \* A
5 inches. There was no other family history of pre-5 L. ]8 f$ X! W+ Z' {3 }/ U
cocious sexual development in the first-degree rela-& T6 Y- p: \5 w2 A% W2 Z
tives. There were no siblings.
) C# O( [" g4 B) zPhysical Examination! T. y6 \9 |8 o3 C/ q. f1 P; \
The physical examination revealed a very active,& T& H) ^. u! g+ W+ d! H
playful, and healthy boy. The vital signs documented
% U0 B X8 K2 Za blood pressure of 85/50 mm Hg, his length was0 }4 O& m ]! ]1 T
90 cm (>97th percentile), and his weight was 14.4 kg
( v J" k& O% d# S9 w# |) G9 J- S(also >97th percentile). The observed yearly growth
: |# m, e/ [: o# d. ~( Qvelocity was 30 cm (12 inches). The examination of( [9 e% A6 H3 i {2 X- U, u
the neck revealed no thyroid enlargement.4 A8 i8 }* F* `5 n5 F
The genitourinary examination was remarkable for
& Y, J. n3 [; C7 y- d$ n- Fenlargement of the penis, with a stretched length of
5 b7 }; O R6 g- Q8 cm and a width of 2 cm. The glans penis was very well! Q( L) c+ i4 ` }8 O
developed. The pubic hair was Tanner II, mostly around
' r6 d5 i) x, G3 j9 o2 f540
) u6 w' l. K+ P% J* s5 E4 Hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" y# Y6 e. Q( j& x4 J
the base of the phallus and was dark and curled. The
' o: w. L. h+ d+ p# L+ s! Utesticular volume was prepubertal at 2 mL each.
0 I3 |; W. }. ^The skin was moist and smooth and somewhat
0 j' E0 ~% r+ Y2 r+ Hoily. No axillary hair was noted. There were no8 m! l% p; W5 x2 ^0 L. T5 r
abnormal skin pigmentations or café-au-lait spots.& S, X7 O1 K: V5 ~! ^
Neurologic evaluation showed deep tendon reflex 2+: u. h+ Q6 _* F+ C H: n
bilateral and symmetrical. There was no suggestion
g0 g8 N3 J6 M5 G$ O, l9 Tof papilledema.; [' W0 G! ?7 n) H. ?5 X+ |0 n
Laboratory Evaluation
! g! P) }6 I; J. K: _0 E. QThe bone age was consistent with 28 months by, Y2 e: a# F% A8 d
using the standard of Greulich and Pyle at a chrono-. [4 x3 ]3 O. \ V. Q) S
logic age of 16 months (advanced).5 Chromosomal
% q% ~9 y7 i9 D1 P5 mkaryotype was 46XY. The thyroid function test& T0 p0 N. z k+ k( n
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
/ n4 O" `+ D- J2 _' M0 S- rlating hormone level was 1.3 µIU/mL (both normal).$ h- e; m8 D; X. L; t; b
The concentrations of serum electrolytes, blood
1 m5 }5 D I/ wurea nitrogen, creatinine, and calcium all were
" o3 _, v: T$ }within normal range for his age. The concentration
% F L- a# C f9 ~of serum 17-hydroxyprogesterone was 16 ng/dL, E$ [* F0 e& s, N
(normal, 3 to 90 ng/dL), androstenedione was 207 m4 o' b* F2 q3 S8 P8 A
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! O2 Y' e2 i8 m' Y' U4 [; f
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
, c" ?3 ?6 G1 k! m* _; rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to# [5 U% v. b2 J- p4 V9 f
49ng/dL), 11-desoxycortisol (specific compound S)/ B( G( C0 f2 o/ t: B# s
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 `# U$ Y j0 D1 u! R/ w# F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 y$ U" h9 c; o4 G8 p! Xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( K: J- V& @) i& F0 \and β-human chorionic gonadotropin was less than
- G, W4 v( s8 m: Q5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 y/ @; C: L0 ~) `: Ustimulating hormone and leuteinizing hormone/ o$ j0 ?% ?% `0 q) ?2 a
concentrations were less than 0.05 mIU/mL
* G- f- O% {1 g; N+ E(prepubertal). O$ |4 ?9 u: J3 U& d C: {
The parents were notified about the laboratory
+ r: p- U$ O( B" {9 kresults and were informed that all of the tests were1 T& |: A" r2 G3 H0 E& r' x
normal except the testosterone level was high. The u" s( }% f ]+ D+ b3 p3 ~: ]
follow-up visit was arranged within a few weeks to
7 ~. A" A2 m. a' \obtain testicular and abdominal sonograms; how-9 S4 C. ` U0 H1 U1 f8 N5 \3 ^0 C
ever, the family did not return for 4 months.; }" U: X3 x6 Z. f, M. ?. x% p, V0 L
Physical examination at this time revealed that the4 d5 L N6 D/ Z F( {3 E
child had grown 2.5 cm in 4 months and had gained
5 F0 Y& j6 z/ \7 y2 kg of weight. Physical examination remained
! e2 g: R( h) o1 G7 |unchanged. Surprisingly, the pubic hair almost com-3 @2 ~& t, t( q) j
pletely disappeared except for a few vellous hairs at. Q$ \; j. y6 f: `% @& T
the base of the phallus. Testicular volume was still 26 {! r% M# b: _. a7 _2 L2 T0 A
mL, and the size of the penis remained unchanged.8 Y. W! S6 x& `) z
The mother also said that the boy was no longer hav-* z) r$ c7 c H. K5 o! ?
ing frequent erections.
0 ?+ u- t+ l3 y3 t( ^ n% xBoth parents were again questioned about use of
$ I3 v) @' q' Z$ Iany ointment/creams that they may have applied to
4 S1 L- o; }4 |1 N$ |( Z6 h# ~the child’s skin. This time the father admitted the9 G0 E" H- U: r! x6 x3 a
Topical Testosterone Exposure / Bhowmick et al 541; P& _, D; J. H4 `% a+ W" G/ |
use of testosterone gel twice daily that he was apply-" t. X6 U6 [2 s, v1 G+ r6 |8 N/ V* B
ing over his own shoulders, chest, and back area for; m$ z$ P' U6 Q1 M) f1 S
a year. The father also revealed he was embarrassed8 E6 G6 r4 Z% g
to disclose that he was using a testosterone gel pre-
) k. w% ]+ r2 L. w7 Uscribed by his family physician for decreased libido
6 n+ A: U! j' a G8 f+ b* h Xsecondary to depression.5 \, D" I/ D( U- d+ d
The child slept in the same bed with parents.$ L8 K J1 l- B' `) Q4 H
The father would hug the baby and hold him on his3 e' J/ w7 I8 R# G" z- P' l$ s
chest for a considerable period of time, causing sig-5 C ]8 e. h! V0 L% d$ U
nificant bare skin contact between baby and father.
+ i% m/ r: u( q( Q5 lThe father also admitted that after the phone call,
* M: [ ^& B7 S$ B% [, Hwhen he learned the testosterone level in the baby3 a: r+ S, u. z4 v6 i' o
was high, he then read the product information
! d0 E. M: k& r% U8 F+ \0 |packet and concluded that it was most likely the rea-% X' o+ a) l& U* l
son for the child’s virilization. At that time, they, B9 g5 r5 a i" {- m4 n
decided to put the baby in a separate bed, and the
, r& V1 z- f- W. q/ p* Y( Afather was not hugging him with bare skin and had9 c/ [; m0 r |1 x) h3 K9 W/ v2 o2 H
been using protective clothing. A repeat testosterone
7 M7 |% ?4 u- g( E1 o+ D ?test was ordered, but the family did not go to the
- h5 ^4 t% b+ _5 C2 ~7 n5 Hlaboratory to obtain the test.! m: ~9 H4 N+ A4 t9 o& u- d
Discussion
' @1 z" s) J9 o9 H; o1 G4 @Precocious puberty in boys is defined as secondary# R5 s5 \& ~! p
sexual development before 9 years of age.1,4
4 |' x6 O$ ~1 p* w4 `- f( IPrecocious puberty is termed as central (true) when) q; ]2 T: x( `+ x' x9 E# W
it is caused by the premature activation of hypo-
3 n/ H- p6 ^6 Nthalamic pituitary gonadal axis. CPP is more com-1 F6 m" A2 d8 `# `5 r8 v: a) I
mon in girls than in boys.1,3 Most boys with CPP2 b( M4 L6 C. V) ^8 e2 a# S
may have a central nervous system lesion that is
2 O" Y6 t- R9 x5 h- l2 Q& t& f1 Xresponsible for the early activation of the hypothal-
u" h1 y8 H: z4 }4 h7 Aamic pituitary gonadal axis.1-3 Thus, greater empha-
' I9 D& e: y- Xsis has been given to neuroradiologic imaging in% ~" e: B. X1 S& n: v
boys with precocious puberty. In addition to viril-
d' M' e7 V8 K, g0 Wization, the clinical hallmark of CPP is the symmet-3 W8 Z& e* z' O. L
rical testicular growth secondary to stimulation by* _2 Z {+ f$ E. K
gonadotropins.1,3
' [( K+ H7 Y& B6 LGonadotropin-independent peripheral preco-, o9 Q( Q! D+ _- Z: ]' d: w
cious puberty in boys also results from inappropriate
" |# ]' K7 r1 Bandrogenic stimulation from either endogenous or
2 ^2 ^" t5 X) E9 k9 yexogenous sources, nonpituitary gonadotropin stim-
`# G$ c- X( aulation, and rare activating mutations.3 Virilizing" k8 ]* e1 v) X
congenital adrenal hyperplasia producing excessive
3 ^0 Y7 @6 N# H5 ]adrenal androgens is a common cause of precocious
1 j9 C$ l, ]9 {- {% Y% ?puberty in boys.3,4
^( d* C- V0 G( R4 `' @0 B1 t$ sThe most common form of congenital adrenal
+ k, A! d1 t( f h' y \1 z; g" m5 \4 phyperplasia is the 21-hydroxylase enzyme deficiency." T* C1 p' Z. D) K5 _
The 11-β hydroxylase deficiency may also result in d! p3 t! P& h2 C5 z2 T( z
excessive adrenal androgen production, and rarely,
8 n2 R5 U6 v! D# Z& z; san adrenal tumor may also cause adrenal androgen: `4 ], @1 a( V% l, c
excess.1,3. U3 `0 [, L6 H- p' Z3 @5 q& I8 w3 A* d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 L7 T3 m7 e1 I% J6 g/ }/ \542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 `% _- }: t1 p7 G v1 G2 L7 B! x5 sA unique entity of male-limited gonadotropin-/ H9 n: S9 a- ]0 F' X2 n3 ]
independent precocious puberty, which is also known4 N9 V- ^* ?. _4 g) c8 m h
as testotoxicosis, may cause precocious puberty at a
; p" N9 m5 ~+ l; k) X g* d: dvery young age. The physical findings in these boys9 Y& j- G, X( z9 E/ J {
with this disorder are full pubertal development,! h& E- V! O+ W. u# r
including bilateral testicular growth, similar to boys9 T5 o3 z5 S$ H' I' d
with CPP. The gonadotropin levels in this disorder- o; Y! c8 K/ N! x5 |+ y
are suppressed to prepubertal levels and do not show
+ o& U' R% E! y" Rpubertal response of gonadotropin after gonadotropin-
$ C) L: q9 z) O/ A; Sreleasing hormone stimulation. This is a sex-linked
' h, e# ^9 W, Xautosomal dominant disorder that affects only; V+ o* E* K. I) i& h
males; therefore, other male members of the family
3 c) N7 }9 v! o! t) G( umay have similar precocious puberty.3
: I, [1 J4 r2 e8 I1 K+ DIn our patient, physical examination was incon-7 B& \7 [: }# A/ H; |9 ?
sistent with true precocious puberty since his testi- w( C$ ^5 c8 _) W
cles were prepubertal in size. However, testotoxicosis
4 w# A- m- r0 b- {was in the differential diagnosis because his father/ Y2 ~* G0 v: g+ e# p& S: r
started puberty somewhat early, and occasionally,+ u( g' _+ p, k% `& [3 L6 ~
testicular enlargement is not that evident in the3 o7 K) t# {, ^
beginning of this process.1 In the absence of a neg-. d2 X& H4 S7 j+ y( {$ n
ative initial history of androgen exposure, our
0 o! K! f, N% L; Z- L3 }biggest concern was virilizing adrenal hyperplasia,5 D7 u2 X2 b- K: s7 w
either 21-hydroxylase deficiency or 11-β hydroxylase
5 V, L- V: U6 u1 y( {deficiency. Those diagnoses were excluded by find-
% y! L; T$ U* v7 u$ h; P9 wing the normal level of adrenal steroids.5 g$ P6 p$ G/ H, Z6 F9 B
The diagnosis of exogenous androgens was strongly
8 e" S" c ?- o0 v/ k# j" U# Dsuspected in a follow-up visit after 4 months because: ^1 T( c# L8 `9 `
the physical examination revealed the complete disap-; P6 f Y8 C @. c( p# o: O
pearance of pubic hair, normal growth velocity, and; E, l8 R1 W" y$ q! K) f/ X
decreased erections. The father admitted using a testos-
' ? p' d* z x! J! }5 b! l# Sterone gel, which he concealed at first visit. He was
9 q) ~3 g9 s3 p. kusing it rather frequently, twice a day. The Physicians’, ?- d8 h, i2 F7 D6 N
Desk Reference, or package insert of this product, gel or
1 G" M! ?! w, r7 P; jcream, cautions about dermal testosterone transfer to
X/ y8 i% V/ K& K8 U' p8 a7 ?- v/ u* munprotected females through direct skin exposure.
4 U6 R: ?- P0 w* p9 GSerum testosterone level was found to be 2 times the. {% N A/ ?4 ^9 O
baseline value in those females who were exposed to
[7 k/ C. B! z6 B/ k: _- H a* {even 15 minutes of direct skin contact with their male- u: U* n( h+ A9 _
partners.6 However, when a shirt covered the applica-/ W, a, D* j% e) f0 T$ y
tion site, this testosterone transfer was prevented.) N+ g+ K k. L: }' J+ \
Our patient’s testosterone level was 60 ng/mL,
: j K. E; a" J8 J+ |7 e: y: `which was clearly high. Some studies suggest that; M2 a0 n, {& k
dermal conversion of testosterone to dihydrotestos-& p0 {" u$ m# V# Z/ F* D/ ]
terone, which is a more potent metabolite, is more- ]" Q9 s: d) B
active in young children exposed to testosterone( r0 z+ d c3 f9 n1 w
exogenously7; however, we did not measure a dihy-
/ k8 Y7 @5 ?& s% T2 @% o, t2 G' Sdrotestosterone level in our patient. In addition to/ o! A* d2 E3 B% Y0 N
virilization, exposure to exogenous testosterone in* O& S0 y& ^$ q; X) B: A( R# }
children results in an increase in growth velocity and3 B; |2 H* m% H
advanced bone age, as seen in our patient.
1 V! s& ?! t1 w2 S+ d% E, QThe long-term effect of androgen exposure during# ^) m2 U" N7 a( j/ C
early childhood on pubertal development and final, u( @4 f9 a: F) L' ?; e
adult height are not fully known and always remain
5 b6 J' M) z+ |0 b! j: i& y& ~" @a concern. Children treated with short-term testos-
5 k& h Z# _0 f5 y" ]terone injection or topical androgen may exhibit some. N" Z8 f, u' W8 V( _
acceleration of the skeletal maturation; however, after% z2 I& F3 G4 v* f# l
cessation of treatment, the rate of bone maturation* n+ f: R% `* e6 j
decelerates and gradually returns to normal.8,9
: V. s2 e+ I5 P0 B4 ~There are conflicting reports and controversy
/ Y6 f1 z) k* R4 h1 ]over the effect of early androgen exposure on adult
) \' }& Z" P4 openile length.10,11 Some reports suggest subnormal. t. Z, T( {3 R3 t
adult penile length, apparently because of downreg-; O4 z$ N( i: s1 @
ulation of androgen receptor number.10,12 However,
+ f; [7 z" U+ ASutherland et al13 did not find a correlation between8 n, G/ V% ]; t& I. P
childhood testosterone exposure and reduced adult
" G9 }9 |6 |; W- h# ^" _2 w Y( w* xpenile length in clinical studies.
7 Y: m b- z6 ZNonetheless, we do not believe our patient is3 Q& L+ @9 F9 y0 g( _
going to experience any of the untoward effects from2 {# z# ?2 I% k# n
testosterone exposure as mentioned earlier because F7 p# Z7 j* c9 B7 v& y# g
the exposure was not for a prolonged period of time.7 P r- T- A! @3 N6 x" Z7 J5 e
Although the bone age was advanced at the time of
' r' n. q! Z$ H) N7 {diagnosis, the child had a normal growth velocity at
' Z! m+ `: B# A$ V3 k$ lthe follow-up visit. It is hoped that his final adult
5 j7 u: {, L$ J/ |/ M3 W$ _/ fheight will not be affected.
" O z; ]5 p: B8 J- LAlthough rarely reported, the widespread avail-
6 h' o2 ^- p5 [& i; A) Gability of androgen products in our society may
! c R# S$ F" c8 {& a+ D( C+ N( H4 [* Tindeed cause more virilization in male or female
& x+ `0 M7 K! [- R+ wchildren than one would realize. Exposure to andro-; C& u- I5 M8 ?4 n
gen products must be considered and specific ques-: b: D9 ]1 H1 i" ^
tioning about the use of a testosterone product or' W" \" L4 _; V, T) A ]% H
gel should be asked of the family members during
' S$ [& U- a( X* cthe evaluation of any children who present with vir-
- y6 B# @# T" W4 }5 R' W5 M7 _ilization or peripheral precocious puberty. The diag-( {6 |1 h, A" { A- Z
nosis can be established by just a few tests and by6 Y9 X* L1 O' C4 O* h" G% O
appropriate history. The inability to obtain such a6 Y7 ]& o$ q9 V* J2 t* X+ \
history, or failure to ask the specific questions, may
6 w2 E+ Y+ C( ~9 |result in extensive, unnecessary, and expensive9 q2 X& f6 u$ L
investigation. The primary care physician should be
% k) {1 J9 P4 laware of this fact, because most of these children
1 _, G- i) R8 R; {1 X" E4 B8 vmay initially present in their practice. The Physicians’+ Z5 _0 Y* s0 s" J$ @+ D
Desk Reference and package insert should also put a& A+ O5 o* ]2 i0 A/ j
warning about the virilizing effect on a male or j( ?% n( O- b+ I
female child who might come in contact with some-
% ]# g; X4 W/ r; w* None using any of these products.4 m, q: F3 E% F# p1 O
References( O5 }' ?; Z% V+ q; f# Y$ Z- ~
1. Styne DM. The testes: disorder of sexual differentiation
3 j4 |! Z" ]0 l' @+ hand puberty in the male. In: Sperling MA, ed. Pediatric" G' E, w s1 `0 p0 @5 H' x/ H
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders; S& ]+ A! I0 A$ x0 F) \
2002: 565-628.1 r1 f$ p, v9 _
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 E0 `5 E5 R q1 Q: O1 `
puberty in children with tumours of the suprasellar pineal |
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