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Sexual Precocity in a 16-Month-Old
+ l+ _! n' j# |; DBoy Induced by Indirect Topical
8 u; u4 n/ G( F) Y c' T. g4 d" FExposure to Testosterone+ f6 M/ m) d! e2 c) _* \ e. h
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 {! C% k- l3 k1 }5 s, a
and Kenneth R. Rettig, MD1
2 R; X3 t% J! pClinical Pediatrics. ^% w/ ?3 ] c( Q6 U/ x
Volume 46 Number 6
3 o. d0 V+ E0 q0 L" H! ` l( \July 2007 540-543/ c# K j" v J. D
© 2007 Sage Publications
% G7 T Q( W! B' k) a3 P) l10.1177/0009922806296651
7 | m" M8 E, r* h2 vhttp://clp.sagepub.com
2 u# r& S3 Y: S; D* qhosted at" ^* E. h5 K! i/ @1 P' G! a( R& ^
http://online.sagepub.com
& ^2 m- F: M+ O' h9 oPrecocious puberty in boys, central or peripheral,
# S9 w0 e, e$ t% }is a significant concern for physicians. Central
N% H; G* K( v [precocious puberty (CPP), which is mediated
: t1 Y$ ]3 T% r3 C* jthrough the hypothalamic pituitary gonadal axis, has( B. I/ H1 H0 |* t# c6 M( t( g
a higher incidence of organic central nervous system# c1 T1 g4 ]) d& B
lesions in boys.1,2 Virilization in boys, as manifested
% T3 C z% y6 d( b6 q- r( Rby enlargement of the penis, development of pubic
% O1 C$ `/ n+ Xhair, and facial acne without enlargement of testi-
+ ]) e9 j' x3 O# K9 z, s2 ucles, suggests peripheral or pseudopuberty.1-3 We
* |. ]9 G6 |& S5 V: |" O4 sreport a 16-month-old boy who presented with the
4 W4 f8 a3 m5 O: t |- Q1 Menlargement of the phallus and pubic hair develop-
) p' G0 v, g$ T# o8 |. ement without testicular enlargement, which was due
* L% J8 T1 i3 W9 Y* T$ {to the unintentional exposure to androgen gel used by' h" s* d G V( q: y h+ b
the father. The family initially concealed this infor-$ E0 c6 N' p3 C1 B% c- K; z
mation, resulting in an extensive work-up for this
, z; F3 V; T- b3 y$ e' ^child. Given the widespread and easy availability of3 N, N+ I2 X, G( \ |7 g
testosterone gel and cream, we believe this is proba-/ |4 D5 Z/ Q0 B/ E0 f1 f& T
bly more common than the rare case report in the b; o( |% l3 J V3 ~
literature.4
! k/ V4 v+ s, u" YPatient Report
/ C6 Z; L9 ~8 K {A 16-month-old white child was referred to the, u& w; u- O( H) s3 U
endocrine clinic by his pediatrician with the concern
: _% t3 o6 ]3 F5 a) b4 F: `of early sexual development. His mother noticed7 f/ U$ W" y* U( N- M
light colored pubic hair development when he was, y9 E$ c; Y, a, H3 Y2 z
From the 1Division of Pediatric Endocrinology, 2University of7 x$ [( {0 f5 A8 ^9 B; ]
South Alabama Medical Center, Mobile, Alabama.
2 k+ F7 S1 L) l! }* F" F8 t& [Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 d/ K1 |8 T0 T9 _% \; o$ UProfessor of Pediatrics, University of South Alabama, College of! b+ {0 v, ?0 W2 t6 J
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 ~$ i5 J" w+ ^0 i
e-mail: [email protected]., q& h; Q6 }9 r' \3 e, a- e; O
about 6 to 7 months old, which progressively became3 x$ }5 E: e4 e0 h: }" }4 l8 u3 X
darker. She was also concerned about the enlarge-6 M. w! m( {( r- @" O+ X/ Y
ment of his penis and frequent erections. The child( [4 R. s4 T, [& G- F$ o" G' W0 C
was the product of a full-term normal delivery, with
$ H4 L: z4 X2 G- U" I/ ma birth weight of 7 lb 14 oz, and birth length of# N1 Z( ^ E4 g" ~! B% Q/ R
20 inches. He was breast-fed throughout the first year
% k$ c7 W0 J- Gof life and was still receiving breast milk along with3 S; C8 V- V& L* j
solid food. He had no hospitalizations or surgery,
0 s# z( n$ u: d; B6 Jand his psychosocial and psychomotor development
. U: `- v* b D) Uwas age appropriate.
5 Z' @+ U8 B: x8 iThe family history was remarkable for the father,3 ^! ?9 w! U4 R- q8 U* j7 L6 @
who was diagnosed with hypothyroidism at age 16,. b1 b1 z1 f4 {$ s0 }8 L9 B
which was treated with thyroxine. The father’s
( U8 c# O6 p- Y2 T8 {height was 6 feet, and he went through a somewhat, v5 ]+ |+ F H1 ]# `
early puberty and had stopped growing by age 14.+ s+ g' h2 w! L( z
The father denied taking any other medication. The- a% G* x0 [5 [
child’s mother was in good health. Her menarche1 `. z: [, h9 `( Y, J
was at 11 years of age, and her height was at 5 feet/ N& m. h3 [- \5 H7 @3 w/ Y, v
5 inches. There was no other family history of pre-
; { F+ v5 ]0 D% Ucocious sexual development in the first-degree rela-
. A8 c5 c, n) f: d; t5 A2 ntives. There were no siblings.! `4 ?8 ~2 [7 l& k2 F
Physical Examination
# a3 w/ a5 P- M6 a( vThe physical examination revealed a very active,; w8 z( \3 q" C& |1 d4 O
playful, and healthy boy. The vital signs documented
2 q% B. M4 j/ a6 g5 ?( Ma blood pressure of 85/50 mm Hg, his length was- d& l4 j: ~. F$ p! n# F; u( M1 k% E
90 cm (>97th percentile), and his weight was 14.4 kg
% y0 ~/ ^; b: B: i y0 q" A6 P(also >97th percentile). The observed yearly growth
8 x7 U1 n% f3 f1 f: L0 U5 `# avelocity was 30 cm (12 inches). The examination of
f$ K# P' q4 e1 [6 Q8 Ithe neck revealed no thyroid enlargement.
) P3 l$ n; T9 t7 m( }& zThe genitourinary examination was remarkable for
b0 m; w4 |. y1 s9 E3 n; Q$ Zenlargement of the penis, with a stretched length of0 a- a7 A1 r, p3 U% ~6 ]
8 cm and a width of 2 cm. The glans penis was very well
0 |( O- U2 p2 q% ?1 n: Udeveloped. The pubic hair was Tanner II, mostly around
% G+ z; f, R2 _- X540: c! k1 j- C6 r/ J) ]+ _
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the base of the phallus and was dark and curled. The3 z- Y- T( |6 _) `5 s9 ?
testicular volume was prepubertal at 2 mL each.
0 ]8 x: e. I3 x' vThe skin was moist and smooth and somewhat
' w) C1 [1 T9 m! [1 Ioily. No axillary hair was noted. There were no
8 E( y) Z0 k! A! ^) M0 s, j- B- Sabnormal skin pigmentations or café-au-lait spots.
! w$ S" ~3 h+ D$ ` `" QNeurologic evaluation showed deep tendon reflex 2+( d. a) y5 p6 I
bilateral and symmetrical. There was no suggestion
0 ^9 X& E+ M9 ?( lof papilledema.
3 x! r3 Y2 d; G1 F5 zLaboratory Evaluation
: ?5 V/ ]; Z, v9 tThe bone age was consistent with 28 months by$ t: {. g, g* W# F( ]. }+ i, S
using the standard of Greulich and Pyle at a chrono-2 w7 t* i \9 i5 M5 R7 v- Z) H
logic age of 16 months (advanced).5 Chromosomal
% z, K; P4 | r4 ]6 M3 \1 M& dkaryotype was 46XY. The thyroid function test
6 ]) T' K9 v" z, _. K* x( y0 zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 u* q( m! E2 l* b% }. k: dlating hormone level was 1.3 µIU/mL (both normal).' r2 d5 K8 ~7 R& |! Y
The concentrations of serum electrolytes, blood& J( n1 I" R) J6 x D
urea nitrogen, creatinine, and calcium all were/ W& Z. q# k1 ] _; f* a: Z* S
within normal range for his age. The concentration
2 d; k8 x# v( Q( _of serum 17-hydroxyprogesterone was 16 ng/dL9 ?. l( Z. r0 l p3 E, q' e. g
(normal, 3 to 90 ng/dL), androstenedione was 20" J) b$ b* z2 y+ s( K8 { P
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ K6 P% L, K9 Bterone was 38 ng/dL (normal, 50 to 760 ng/dL),7 a. e9 Y9 [' b! s9 A
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 e; ]8 M. r5 `* d
49ng/dL), 11-desoxycortisol (specific compound S): ~' C9 ?5 V4 @) R
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 L' h- s( { Z" k5 k
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
" ?! U1 C, V. H% ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),0 Y5 n3 `, @. S/ I0 z
and β-human chorionic gonadotropin was less than n( Q' o* m; D \1 o
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# A0 @ V7 r3 ]7 `; h6 n1 e* [stimulating hormone and leuteinizing hormone
: i! O% n: H* _: L- n# @; C' uconcentrations were less than 0.05 mIU/mL
$ `1 S, t$ M) J+ E" t+ i- y( J(prepubertal).$ f$ n- T+ V7 K9 X( o: H
The parents were notified about the laboratory8 t$ x/ F6 h" N! ^* E8 a* d0 K& Q' R
results and were informed that all of the tests were/ D3 B* U8 y( M
normal except the testosterone level was high. The
' T- x/ ~- `1 U0 v9 X- h* h) k( R n0 zfollow-up visit was arranged within a few weeks to
+ J) f! F( c5 }& v) V+ dobtain testicular and abdominal sonograms; how-
* g) \/ c7 Q oever, the family did not return for 4 months.
4 |0 b" [1 [$ f. ` Z! F2 nPhysical examination at this time revealed that the
$ D2 |3 C. c3 G4 D4 Tchild had grown 2.5 cm in 4 months and had gained
7 x* g! O& N7 C$ m! ~2 d2 kg of weight. Physical examination remained/ E/ ~5 g( Y8 K
unchanged. Surprisingly, the pubic hair almost com-
' X6 G. M3 c8 V1 I, k) G8 kpletely disappeared except for a few vellous hairs at& i6 q4 o" ^" D) k9 r
the base of the phallus. Testicular volume was still 2
# E" f6 {0 T cmL, and the size of the penis remained unchanged.
- C2 P0 c- u5 K) U+ MThe mother also said that the boy was no longer hav-( a, w* r+ c) o) ~8 @7 A$ K1 Q! s
ing frequent erections.
+ T9 u2 L1 X# @3 S7 @/ W9 SBoth parents were again questioned about use of; ~9 f1 U. Q6 A# {5 ]8 _' P) r
any ointment/creams that they may have applied to+ y( w+ q) f! L" r$ C9 i1 \
the child’s skin. This time the father admitted the- ~! \: p5 J) M7 Y6 n7 i, r0 _
Topical Testosterone Exposure / Bhowmick et al 5413 p! b4 n4 t$ X' Q8 T2 ], e
use of testosterone gel twice daily that he was apply-. b4 T3 R' j7 i; E! P: B0 s
ing over his own shoulders, chest, and back area for
- V& E% @& H! P4 A, `( ha year. The father also revealed he was embarrassed! q# X5 h( C) c! h
to disclose that he was using a testosterone gel pre-% t! [# Y( i! M
scribed by his family physician for decreased libido) u9 L! k. W0 y9 X
secondary to depression.8 b* v* H: a- _3 k, c
The child slept in the same bed with parents.
" m% V6 v# ?$ H) V- G9 YThe father would hug the baby and hold him on his
( P Z7 c; ~( V) s' x4 rchest for a considerable period of time, causing sig-" Z' z* P$ G6 G" L. `1 W, P/ h
nificant bare skin contact between baby and father.) T! H# p) L/ J; \3 _" N$ `
The father also admitted that after the phone call,
4 R- R0 Z' R& w. I' s4 z. b T) {7 Y4 Zwhen he learned the testosterone level in the baby; j# y3 B9 |) _4 V! B4 L$ y
was high, he then read the product information
" m9 M$ ]; z5 X8 q/ ]4 {packet and concluded that it was most likely the rea-
* H3 I# }9 E4 ?, O$ m/ fson for the child’s virilization. At that time, they0 Y/ i$ p, X7 j; z4 L$ C& Y
decided to put the baby in a separate bed, and the6 Z' ^$ w; p3 p( H8 S c; t& f
father was not hugging him with bare skin and had
$ C+ Z+ D5 U2 I! rbeen using protective clothing. A repeat testosterone1 A- z; Q/ F. K( @
test was ordered, but the family did not go to the
9 ^. ~* N8 ^, w0 t( p/ @ a2 A% {laboratory to obtain the test.4 U+ I) F1 i- x; ^' n& Y
Discussion& o! w$ Q) X: z8 s% [% F
Precocious puberty in boys is defined as secondary* ~- T3 H8 y Y/ H
sexual development before 9 years of age.1,4
/ N8 ]# i |# F; w. r+ Z: NPrecocious puberty is termed as central (true) when
2 h2 o# w6 W# jit is caused by the premature activation of hypo-2 I J1 h; }/ L8 ]* D; \
thalamic pituitary gonadal axis. CPP is more com-: j2 E% e- X0 A6 i, a8 Q. k4 a" \; m
mon in girls than in boys.1,3 Most boys with CPP
2 W( _( n- d) v( `6 @! Y6 b7 t- pmay have a central nervous system lesion that is# l5 B) D! `8 m
responsible for the early activation of the hypothal-1 P) g8 @# Y5 L8 D3 N
amic pituitary gonadal axis.1-3 Thus, greater empha-; X2 {; |' y* X" R( @
sis has been given to neuroradiologic imaging in
8 ]. ]9 f) l# E( a1 W/ d# cboys with precocious puberty. In addition to viril-
' e+ e) W+ b( r7 x. a/ @( }3 Gization, the clinical hallmark of CPP is the symmet-/ Z7 H% C9 _, c( ^2 M: }
rical testicular growth secondary to stimulation by! L" b* V/ ~4 n2 ]. v2 Z% a
gonadotropins.1,31 E9 K8 o1 o* [1 w- P2 }
Gonadotropin-independent peripheral preco-
/ b3 ?3 v& M; V5 [! |# Hcious puberty in boys also results from inappropriate! e$ I9 f- E% a+ m V: U
androgenic stimulation from either endogenous or+ L, {: J* g& ~. c9 D
exogenous sources, nonpituitary gonadotropin stim-
+ g. [- R3 H; l6 _# h# N4 aulation, and rare activating mutations.3 Virilizing
7 H) m2 d; X5 M& fcongenital adrenal hyperplasia producing excessive5 v/ o8 f' `( @3 ` m/ O6 @. A
adrenal androgens is a common cause of precocious
& u4 L4 b" ]4 Y; O$ k( mpuberty in boys.3,4. t6 p5 g {! Z
The most common form of congenital adrenal
! Y# J$ h2 e- \+ Zhyperplasia is the 21-hydroxylase enzyme deficiency.
- P2 c, R7 h0 p/ W8 G& xThe 11-β hydroxylase deficiency may also result in* F6 ~: o. x* I5 _
excessive adrenal androgen production, and rarely,) b% s# b% l7 N S7 ^, f1 q% s( x, q
an adrenal tumor may also cause adrenal androgen( T, e! i% Q: P+ I
excess.1,3, S8 Q8 ^# t% s' p. {. Q/ p
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& S: ^- M! @: M/ j! [6 {542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 M/ X( B% ]4 A) h) L4 [8 J
A unique entity of male-limited gonadotropin-2 u! b: s0 }% V
independent precocious puberty, which is also known
+ U8 X. [; t) fas testotoxicosis, may cause precocious puberty at a
' Z* g: B! G+ S0 Jvery young age. The physical findings in these boys
. L, B/ p+ `% s5 Ywith this disorder are full pubertal development,
( M$ n; t- W3 r6 `4 R+ qincluding bilateral testicular growth, similar to boys$ ?* e* M( b+ \- {8 x
with CPP. The gonadotropin levels in this disorder- I- ]( O% \! c# s! [( _2 ^
are suppressed to prepubertal levels and do not show) q5 D u- N; n; X. f2 O% [
pubertal response of gonadotropin after gonadotropin-0 A% t( s- m" e: d% g: ~9 ]
releasing hormone stimulation. This is a sex-linked9 ^6 D9 {( V) v n& n: I( F
autosomal dominant disorder that affects only5 @8 V: p0 G4 i+ L4 J" b+ Y
males; therefore, other male members of the family) Z( ~2 u7 {2 p. U
may have similar precocious puberty.3
1 P: W* O4 j5 V+ [In our patient, physical examination was incon-
4 v- l: d& Z# G0 h1 Osistent with true precocious puberty since his testi-
( m% M: ~: B- F+ C0 g* `/ zcles were prepubertal in size. However, testotoxicosis
) h# l' W: `5 ]was in the differential diagnosis because his father' q* M& t6 ?5 l8 F& `
started puberty somewhat early, and occasionally,
7 ], N, j/ M& d* btesticular enlargement is not that evident in the
* C' X( k/ J# p8 r: C9 fbeginning of this process.1 In the absence of a neg-
0 Y1 ~1 K+ B" e; c2 `. [ative initial history of androgen exposure, our
/ C. R$ H0 f; B3 bbiggest concern was virilizing adrenal hyperplasia,
& [! {' g$ t4 s4 F0 Seither 21-hydroxylase deficiency or 11-β hydroxylase; c+ N+ y! H# n7 Z; V
deficiency. Those diagnoses were excluded by find-; V F) L: J6 O) j: K" J
ing the normal level of adrenal steroids.
6 q) w- G* t) I5 J/ l& K. V% e+ ZThe diagnosis of exogenous androgens was strongly. h+ S' J5 [) v3 T7 `' t
suspected in a follow-up visit after 4 months because
' g3 @; W1 ~) Lthe physical examination revealed the complete disap-& E' k q: o4 N* o- z5 ~! E
pearance of pubic hair, normal growth velocity, and% ^: U0 l! H8 R d) x$ \# ]
decreased erections. The father admitted using a testos-% \/ D2 g' b% T" \
terone gel, which he concealed at first visit. He was
! t/ k# X5 E% x. L6 o9 x, Ousing it rather frequently, twice a day. The Physicians’- {* B I( m, L7 `1 q% n' e( H2 E
Desk Reference, or package insert of this product, gel or# U" [0 q/ j& p: J1 [/ T4 ^
cream, cautions about dermal testosterone transfer to2 y( A8 L1 m( [0 k. a9 E0 T
unprotected females through direct skin exposure.* [4 Q) u$ n+ q4 j# S" w
Serum testosterone level was found to be 2 times the# X# I0 G c/ s8 ]7 `
baseline value in those females who were exposed to$ O4 |) J" w& X2 [+ f& L- e0 T4 [4 K8 X
even 15 minutes of direct skin contact with their male
0 a4 u, \; v: Lpartners.6 However, when a shirt covered the applica-8 k# q) |9 d3 |& T ]
tion site, this testosterone transfer was prevented.
( G& O( t; p+ [3 i7 Y& cOur patient’s testosterone level was 60 ng/mL,
& `; ^7 B3 h5 ^( a' ~which was clearly high. Some studies suggest that* J. O; \4 d, r: ~( @
dermal conversion of testosterone to dihydrotestos-
" i' q2 h5 c" z0 h$ \terone, which is a more potent metabolite, is more) [" O, J4 a: K9 M; s
active in young children exposed to testosterone8 H$ M2 n* q3 Y
exogenously7; however, we did not measure a dihy-
. }# G4 l; B. Y6 F. Adrotestosterone level in our patient. In addition to0 x7 [! t+ s/ E6 b" d
virilization, exposure to exogenous testosterone in
r1 H1 Y. b' rchildren results in an increase in growth velocity and
0 X7 I! \; v: v( \. ~: Jadvanced bone age, as seen in our patient.
6 k1 h8 x! g$ |, h# A8 kThe long-term effect of androgen exposure during
1 d6 z, e5 `% w" p5 T: z, M1 pearly childhood on pubertal development and final
& D) S6 u# a" Yadult height are not fully known and always remain" x/ o# a# Y+ V5 q& p3 d6 ` U6 s
a concern. Children treated with short-term testos-
7 q( O* S1 { g3 x( nterone injection or topical androgen may exhibit some8 l6 h B, S+ y9 ?" K1 i6 E
acceleration of the skeletal maturation; however, after
9 ]! [# X$ m, b+ G) w' G* xcessation of treatment, the rate of bone maturation
& o3 I- l+ R3 c( v$ X/ Odecelerates and gradually returns to normal.8,9
( \, j* {6 f8 y, k0 gThere are conflicting reports and controversy
) k3 a- W6 l9 Q y+ @( `% q; d% c* mover the effect of early androgen exposure on adult- m8 u" V8 z& }8 z7 N8 x. C
penile length.10,11 Some reports suggest subnormal/ `1 t x4 v! I
adult penile length, apparently because of downreg-! \' z5 o. S! i, d* A
ulation of androgen receptor number.10,12 However,
$ G- A2 Y7 h5 _6 t) n) k& USutherland et al13 did not find a correlation between+ U, Q3 E% ]. X
childhood testosterone exposure and reduced adult
3 y5 s+ \5 H/ \2 W/ ?) ?; s, O0 Gpenile length in clinical studies.& M: q& ^" a1 U& }, W& Q
Nonetheless, we do not believe our patient is
( `' d* P6 }, n$ X4 lgoing to experience any of the untoward effects from
* ~' V1 l+ c% R0 n, Ctestosterone exposure as mentioned earlier because
* \# S K/ x5 k2 z. Athe exposure was not for a prolonged period of time.
) G4 ~3 [! K% k/ tAlthough the bone age was advanced at the time of' A) X% U) x* F$ T0 G& w
diagnosis, the child had a normal growth velocity at } s) l# C& v$ d9 C4 k
the follow-up visit. It is hoped that his final adult% p7 q% k" A. a1 m g, r, ^
height will not be affected.9 s _* H6 b7 O1 v- z
Although rarely reported, the widespread avail-
5 q4 X# v5 t& Fability of androgen products in our society may3 A# t9 L8 p) S- _; M
indeed cause more virilization in male or female' g6 u% l, r9 {+ ^6 z
children than one would realize. Exposure to andro-3 }5 _# |$ H% _6 {
gen products must be considered and specific ques-
$ _- n% s7 i |( ]+ n0 btioning about the use of a testosterone product or+ o8 |& t) ]4 Q% A8 b$ N4 [+ ~+ Z
gel should be asked of the family members during
- R; b0 f# n% _; wthe evaluation of any children who present with vir-
5 n; S. R- c& V+ l3 W. W- ]ilization or peripheral precocious puberty. The diag-
. h; G' u( a- @/ jnosis can be established by just a few tests and by5 G7 c5 U7 D. X# [. N+ s
appropriate history. The inability to obtain such a
5 Z/ Q/ |! R \3 i% whistory, or failure to ask the specific questions, may
7 @8 @2 A3 P; {- ~result in extensive, unnecessary, and expensive
' Z4 \: W2 @' l) Tinvestigation. The primary care physician should be( I" d: A% T0 [$ E1 U( r
aware of this fact, because most of these children
% [. D6 E; o* Z4 s0 imay initially present in their practice. The Physicians’
6 e. S% Q9 ?3 {+ q* \Desk Reference and package insert should also put a; x+ _8 ?3 |4 Y' K, R/ n
warning about the virilizing effect on a male or
. T5 K% F8 s% n/ S- \female child who might come in contact with some-
( ~- o% a# r4 R+ I' fone using any of these products.
+ V( a' ]3 Y T2 n* uReferences: E. [. z0 y% h' n3 J8 e# o6 [. I
1. Styne DM. The testes: disorder of sexual differentiation
5 r0 @/ n" Z2 e: U# c# a( C$ i2 sand puberty in the male. In: Sperling MA, ed. Pediatric
9 @8 J' G$ j5 p5 [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& E% Q3 P; U4 G2 q
2002: 565-628." l$ J$ o W) M* a
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 y. U! U0 y" D2 x8 O) _2 P9 c2 Dpuberty in children with tumours of the suprasellar pineal |
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