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Sexual Precocity in a 16-Month-Old
. b8 x7 K) Y x kBoy Induced by Indirect Topical
8 j2 \; E1 ?: B8 a* A0 a2 @& uExposure to Testosterone P4 e0 h# B9 [
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ f) O5 |+ R( W( ]* ^: Land Kenneth R. Rettig, MD1" F9 d( c/ R ^! ^2 j9 z+ j
Clinical Pediatrics: d3 X" {) |- j% E3 Z
Volume 46 Number 68 N! p" s& q- s: h2 C
July 2007 540-543
V9 T4 ?3 `% L© 2007 Sage Publications/ ]! ^6 v' E6 |* h. W
10.1177/0009922806296651
6 X# ]0 U& L3 z* M( Bhttp://clp.sagepub.com
; B6 s! ?0 U% G- s4 Ehosted at
. }. {! J6 {! fhttp://online.sagepub.com& l6 z. [, A8 a' o% K. l$ M
Precocious puberty in boys, central or peripheral,
5 _: f0 e. A t# u; Iis a significant concern for physicians. Central
- c& I* F& @3 b, w( ^0 N; gprecocious puberty (CPP), which is mediated3 e" Q0 b9 J& h/ X
through the hypothalamic pituitary gonadal axis, has* D# t- ] j8 u" `; E* A- r$ X
a higher incidence of organic central nervous system
- y( k! X) X: _, v8 p# Hlesions in boys.1,2 Virilization in boys, as manifested# q3 S* g5 O" C; \
by enlargement of the penis, development of pubic2 v* E( Z! s; H: }
hair, and facial acne without enlargement of testi-. ]. J2 _' d2 C* ]* s* W( ^
cles, suggests peripheral or pseudopuberty.1-3 We
; L7 h( N& [. ~$ }report a 16-month-old boy who presented with the
$ a+ ` C' z6 Tenlargement of the phallus and pubic hair develop-3 Q$ f. Y. Z. u! g2 x
ment without testicular enlargement, which was due
3 x1 a! a" ^ k" xto the unintentional exposure to androgen gel used by, N4 x5 d5 L6 L9 c0 R
the father. The family initially concealed this infor-
8 z8 w6 {0 j1 c5 O+ d; F, |2 Zmation, resulting in an extensive work-up for this
7 w% ^$ r1 l4 v( U9 V0 x; Cchild. Given the widespread and easy availability of3 P. D% M8 X; @
testosterone gel and cream, we believe this is proba-
7 e. B* B/ T3 q$ C$ G R7 G) kbly more common than the rare case report in the8 T' _: P0 y! l2 m
literature.44 V) Q4 G& \+ l9 ^
Patient Report$ T5 [7 j* R$ a0 X8 f( y
A 16-month-old white child was referred to the' ?3 R6 v# q7 b, O$ \
endocrine clinic by his pediatrician with the concern) X& j" T b, h) r; r* A
of early sexual development. His mother noticed' E7 W% \2 `2 D
light colored pubic hair development when he was
- b8 l5 F3 G3 n0 M2 ?, O$ ~From the 1Division of Pediatric Endocrinology, 2University of
+ b; q0 I2 g) K# k0 n( oSouth Alabama Medical Center, Mobile, Alabama.4 L5 T. W" R3 i( t& B
Address correspondence to: Samar K. Bhowmick, MD, FACE,
! X0 w. t( x _! K( pProfessor of Pediatrics, University of South Alabama, College of2 e' ~5 x! h$ I0 Y7 U5 l- V2 f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 L( f, ~" Q) B
e-mail: [email protected].
# t4 r/ t" j- ]- d# Nabout 6 to 7 months old, which progressively became+ B: P, J# ?$ N$ x; l* E
darker. She was also concerned about the enlarge-
5 s: _& M, [1 u/ \0 cment of his penis and frequent erections. The child( J; h& z' E" f$ |' Z2 m) Z
was the product of a full-term normal delivery, with
& m( h4 i- L" @9 V) T5 X1 W: s/ ea birth weight of 7 lb 14 oz, and birth length of
" [( h+ T! q5 h, R( @. G5 Y20 inches. He was breast-fed throughout the first year
* R: e6 i- N6 t+ zof life and was still receiving breast milk along with B; Q, i5 S7 V+ j2 {: F! C- H/ o
solid food. He had no hospitalizations or surgery,
* [/ X& A( ^; J* {8 h; C+ x9 Rand his psychosocial and psychomotor development0 j. B- Q2 r* X) t
was age appropriate.* q2 [! [' D1 ?9 M0 A1 k! m8 D/ J2 ?. e
The family history was remarkable for the father,2 ^! ?$ F. \; U5 `2 p, F- f
who was diagnosed with hypothyroidism at age 16,: l# u- d' G t( s x
which was treated with thyroxine. The father’s" x5 N) o- h- v# d2 u# h- h: l
height was 6 feet, and he went through a somewhat
, d/ d: E+ V. X5 searly puberty and had stopped growing by age 14.
3 d) y/ D6 U3 [, Y0 v) }: bThe father denied taking any other medication. The# D3 y; m8 J1 s
child’s mother was in good health. Her menarche
9 a; k, P u: F# k4 C# |was at 11 years of age, and her height was at 5 feet9 j9 a' P L4 _# ^4 F3 F" D
5 inches. There was no other family history of pre-
) e# R+ I1 E |( Jcocious sexual development in the first-degree rela-: `# C& B$ D* \1 Y; ^
tives. There were no siblings.
. n" j( a9 ^/ o' V+ H! _+ vPhysical Examination. Y$ k8 i2 L. g
The physical examination revealed a very active,8 y3 q8 j# ^) \* G' {
playful, and healthy boy. The vital signs documented
: v& A7 s% v+ R8 ~5 C+ Ua blood pressure of 85/50 mm Hg, his length was
4 U6 O& \) C, X6 z/ A90 cm (>97th percentile), and his weight was 14.4 kg9 C6 b0 t! s2 G: ]6 Z7 I. t
(also >97th percentile). The observed yearly growth
, I+ `' ~; M& F7 I) Dvelocity was 30 cm (12 inches). The examination of1 o, R+ i, c5 I( b* J( M0 y
the neck revealed no thyroid enlargement.
4 w" L4 P1 Q% U9 s& e2 I( Y; HThe genitourinary examination was remarkable for
+ ]+ p, D5 ^) q% l" p" Menlargement of the penis, with a stretched length of
* _& F0 W$ n L* y, ?8 cm and a width of 2 cm. The glans penis was very well
& T, y3 K$ n) ~: e- y6 S0 d9 K& Fdeveloped. The pubic hair was Tanner II, mostly around3 D, Z) ] C3 S' _7 [
540
/ d8 A! z; y) K# Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) M) H/ }5 L6 J! y5 T. cthe base of the phallus and was dark and curled. The8 D6 b/ j$ ~3 q [0 T
testicular volume was prepubertal at 2 mL each." c" h" C1 h& |' t
The skin was moist and smooth and somewhat
; p3 d# F' P" Xoily. No axillary hair was noted. There were no+ L# Z0 L) v! S" y) Q1 \* ^
abnormal skin pigmentations or café-au-lait spots.
. t4 u( g J7 V' L+ L( pNeurologic evaluation showed deep tendon reflex 2+7 G# A/ |! ^( L; D3 c
bilateral and symmetrical. There was no suggestion1 U8 r( ~! t; [% o8 x
of papilledema.
" S2 k" a* r+ V9 J( yLaboratory Evaluation
% L1 n: ~* }; M- }* _6 Q4 `. mThe bone age was consistent with 28 months by/ Q& y$ W. |. f8 l. h+ T
using the standard of Greulich and Pyle at a chrono-
" O. q& ~# c' w" g1 [" Y t4 M7 ^logic age of 16 months (advanced).5 Chromosomal" r0 b, ~- R z" Z. u
karyotype was 46XY. The thyroid function test
4 a( X; X: ~1 g1 Q! _5 `showed a free T4 of 1.69 ng/dL, and thyroid stimu-
, w1 H9 m8 G4 E: [3 b- Hlating hormone level was 1.3 µIU/mL (both normal).6 y' f5 @5 ~1 W! ^& V6 [% e# X
The concentrations of serum electrolytes, blood9 r' I5 I4 `6 T8 q
urea nitrogen, creatinine, and calcium all were9 w( ]$ y& p9 O5 J5 R5 L7 X
within normal range for his age. The concentration
& x3 e* b, k) w5 Aof serum 17-hydroxyprogesterone was 16 ng/dL
: s2 |& b! p% Z(normal, 3 to 90 ng/dL), androstenedione was 20
) f w! z7 d! M, Y9 j: zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& t& q1 k; [# l4 L6 X, u! ^
terone was 38 ng/dL (normal, 50 to 760 ng/dL),, m( R3 v0 L! }8 f
desoxycorticosterone was 4.3 ng/dL (normal, 7 to( o B% n/ \( V7 G
49ng/dL), 11-desoxycortisol (specific compound S); a! r' {- ~7 }* \& K% v9 \* E
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. R3 \9 r* G* ^8 ~
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 P/ L( l9 x% E3 N8 |1 a1 K2 I
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 \8 e6 h$ R. o9 p, ?' f1 e
and β-human chorionic gonadotropin was less than6 U% A* q7 K9 r" w
5 mIU/mL (normal <5 mIU/mL). Serum follicular
! e2 {8 r& O6 x5 r5 `; g+ x7 Qstimulating hormone and leuteinizing hormone* S- C% Y/ {! H l! N9 ]2 |
concentrations were less than 0.05 mIU/mL
% x+ h! ~; n+ [- U l; {; r(prepubertal).3 \: j6 r. s$ x3 J2 u' g& _
The parents were notified about the laboratory$ W/ ^* Y5 q4 N! P/ [' s
results and were informed that all of the tests were) P3 t/ {1 B- Y; i
normal except the testosterone level was high. The* @( ~* z$ f6 [: d/ j7 _& a& c
follow-up visit was arranged within a few weeks to2 }$ B$ H* X" X' D. p0 J/ @
obtain testicular and abdominal sonograms; how-7 X2 ?9 y3 W" [2 R2 a# n E
ever, the family did not return for 4 months.. Y+ ]) a5 `! C; U
Physical examination at this time revealed that the
" T) n9 k6 G" c: F- Q4 ?child had grown 2.5 cm in 4 months and had gained- p. V% J/ D5 U3 J# n5 d& n2 g7 @
2 kg of weight. Physical examination remained; f1 f+ r9 N: @9 |, {. q
unchanged. Surprisingly, the pubic hair almost com-
% _. i6 i; [/ q. Npletely disappeared except for a few vellous hairs at
6 [% \9 K+ _# R9 f+ }the base of the phallus. Testicular volume was still 2. N& }4 I0 I* N* d: Y
mL, and the size of the penis remained unchanged.& X0 F* ^ N. j. D9 v4 ~
The mother also said that the boy was no longer hav-
1 ~' n3 K% W1 r* _- j& Zing frequent erections.# d) w& s6 w/ Q' s v P
Both parents were again questioned about use of! w- b7 W& e2 K; R
any ointment/creams that they may have applied to
0 y( g0 t% |' y! U/ _the child’s skin. This time the father admitted the) k9 d& _1 V3 x
Topical Testosterone Exposure / Bhowmick et al 541
# d+ o3 G! C2 R3 S- ~use of testosterone gel twice daily that he was apply-
D* l% V) d1 W9 N; Xing over his own shoulders, chest, and back area for
- ^; S7 O% W* u0 T$ n( }, w7 Ba year. The father also revealed he was embarrassed
! B- |# Y3 E4 X+ ~' R0 Y. Vto disclose that he was using a testosterone gel pre-3 B; s4 c& P2 |! A( I8 ?
scribed by his family physician for decreased libido
% H1 ] O& I9 Fsecondary to depression.
9 u. u6 W9 H# @# r+ XThe child slept in the same bed with parents.
6 P, c7 A5 @& U, OThe father would hug the baby and hold him on his
( _, [/ ^/ v" o9 mchest for a considerable period of time, causing sig- q# I7 B9 B1 d1 T' N: |0 X
nificant bare skin contact between baby and father.- T1 s3 C: H9 v7 d- ?1 q6 H* a
The father also admitted that after the phone call,1 Y7 c7 q" v7 n! s8 F$ R
when he learned the testosterone level in the baby
" B7 A0 ]" u& ^! j" \ jwas high, he then read the product information+ D# t: `. E# B3 d G
packet and concluded that it was most likely the rea-% m3 M O% u& w4 _# I7 T7 f8 R/ s
son for the child’s virilization. At that time, they* w5 h7 K+ a' t# @
decided to put the baby in a separate bed, and the5 `% q: P$ [/ E) r
father was not hugging him with bare skin and had
8 V8 g0 w! ^- s% Cbeen using protective clothing. A repeat testosterone6 A0 T7 |5 T+ o
test was ordered, but the family did not go to the0 c) |& Q- l/ j1 f! x. @
laboratory to obtain the test.
. Y g8 ~( J8 Z$ A6 j& XDiscussion* X8 A4 L# T9 b& Y% i; p
Precocious puberty in boys is defined as secondary
5 f& t( \3 k% S) z( Z2 J# V, [+ Ssexual development before 9 years of age.1,4
) O1 n! Y4 H8 B0 _8 ?- g, pPrecocious puberty is termed as central (true) when
3 \7 a3 H' R0 ~. l3 @: I; n: ?it is caused by the premature activation of hypo-" x+ {9 w! L) g' N R
thalamic pituitary gonadal axis. CPP is more com-
/ O' }. }% p; p; ~/ rmon in girls than in boys.1,3 Most boys with CPP
/ M' W+ x' A* h6 ^6 \, e; }may have a central nervous system lesion that is' I* y x- c* M: {; t9 e0 g5 I/ e
responsible for the early activation of the hypothal-$ N3 e: C+ A- \) u6 }
amic pituitary gonadal axis.1-3 Thus, greater empha-
6 R t6 z- J3 f. D9 ^sis has been given to neuroradiologic imaging in
$ d1 a. u$ ]0 r) E. H- Tboys with precocious puberty. In addition to viril-) G7 y4 ? z6 i. _/ H+ W
ization, the clinical hallmark of CPP is the symmet-
: [4 ~, x$ r! F, z7 zrical testicular growth secondary to stimulation by" m1 m9 o2 m0 ]* r; Q
gonadotropins.1,3
; {6 ?$ @2 e7 |Gonadotropin-independent peripheral preco-
5 D; p P$ S vcious puberty in boys also results from inappropriate
# z6 i; E! y, r2 f9 e% mandrogenic stimulation from either endogenous or- T( T) V! c6 h; z: B
exogenous sources, nonpituitary gonadotropin stim-
) ]% U* e% R! O- z1 Gulation, and rare activating mutations.3 Virilizing
" Y' y# j6 V0 t' L Ucongenital adrenal hyperplasia producing excessive
' G- h: O7 [- ?1 Xadrenal androgens is a common cause of precocious
) u$ h* z/ D2 y1 q% ppuberty in boys.3,49 `- [9 h1 p/ ?; V2 f" ^
The most common form of congenital adrenal
+ F, D6 n) H! w8 w7 |7 I% A. lhyperplasia is the 21-hydroxylase enzyme deficiency.: d ]0 i5 T% a/ Z* A% u, X3 e: m& p
The 11-β hydroxylase deficiency may also result in
@; v) m- ^) V, m6 e# texcessive adrenal androgen production, and rarely,
( n& L3 G7 V5 g- H6 w' t/ C) Xan adrenal tumor may also cause adrenal androgen' A' [! |- v& P) U# K8 A) o
excess.1,3' V4 G9 b' c& G* w2 J+ E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ U1 W! U9 c) a9 g! w4 d
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! P9 ^0 b) c7 T3 B
A unique entity of male-limited gonadotropin- A+ Q" J: A, {
independent precocious puberty, which is also known
) `4 Z$ ~* E+ e4 E' X6 {" Pas testotoxicosis, may cause precocious puberty at a
2 S7 D2 h, h2 r" W8 I0 m6 mvery young age. The physical findings in these boys
7 R& p) y4 r. Awith this disorder are full pubertal development,+ e6 H' E. K* W
including bilateral testicular growth, similar to boys
; @& f% V8 `( t+ swith CPP. The gonadotropin levels in this disorder
% [- _& F: f- q( F/ i2 n$ u- F+ J pare suppressed to prepubertal levels and do not show9 G2 w; F: G8 f/ t, }
pubertal response of gonadotropin after gonadotropin-
" \4 ^; X( O& _releasing hormone stimulation. This is a sex-linked
& N6 G) H7 R& ], \$ Kautosomal dominant disorder that affects only
& ^6 W, Q7 A) n8 k7 Emales; therefore, other male members of the family
1 ^1 ^4 G3 G4 ?% K( amay have similar precocious puberty.3
4 f `0 P4 L8 U$ C+ nIn our patient, physical examination was incon-
! z) O) K* a6 H7 B5 b& r6 |sistent with true precocious puberty since his testi-
% n/ \+ T3 V3 @( `: M/ s$ ~cles were prepubertal in size. However, testotoxicosis8 ?: g0 M( @0 v
was in the differential diagnosis because his father
0 c. ~( ~5 l+ h6 Zstarted puberty somewhat early, and occasionally,5 V7 e3 @2 v$ \3 ^
testicular enlargement is not that evident in the: @7 r+ C( c F' p* c* u, ~
beginning of this process.1 In the absence of a neg-& p! ^8 H: B- g* v8 H* \
ative initial history of androgen exposure, our
! F! f$ i" A, u: T! _; l( U9 i* Gbiggest concern was virilizing adrenal hyperplasia,
) j$ C: A1 {! c( u) A% reither 21-hydroxylase deficiency or 11-β hydroxylase8 Y$ I' n9 e# g' y% }. Z& T
deficiency. Those diagnoses were excluded by find-6 v) T! \2 B! [' D5 r' X' ^5 k& i
ing the normal level of adrenal steroids.
- h8 e, c! t3 a: X+ L0 Y7 s0 NThe diagnosis of exogenous androgens was strongly5 s! R' ]; }* t6 x
suspected in a follow-up visit after 4 months because! b! p/ K- H- `- I/ a( J
the physical examination revealed the complete disap-
2 g. K6 `( ^3 Z6 [2 Kpearance of pubic hair, normal growth velocity, and: @. M3 a" G5 G1 [
decreased erections. The father admitted using a testos-
% a$ S c: M; t7 Z- K6 mterone gel, which he concealed at first visit. He was" D( n2 U, a5 T, H
using it rather frequently, twice a day. The Physicians’2 ]6 G. {6 x9 P
Desk Reference, or package insert of this product, gel or. B6 ^; ^+ r, D1 r4 |+ d6 V
cream, cautions about dermal testosterone transfer to, u7 O. J" Q% S: s6 Y- `) f7 h
unprotected females through direct skin exposure.
# j/ g, f; |2 y+ j; L7 uSerum testosterone level was found to be 2 times the+ C% x, h/ u& {, i+ l. S) z
baseline value in those females who were exposed to
& [2 L0 ?' z- m% t+ f* Z0 _! w7 M& `even 15 minutes of direct skin contact with their male9 Q5 v$ ]& d# V4 {
partners.6 However, when a shirt covered the applica-
8 ~& Q4 b# h, J+ F1 o4 W9 `) I/ X I, Stion site, this testosterone transfer was prevented.
6 H3 O& [* K" eOur patient’s testosterone level was 60 ng/mL,2 Y% s3 }' M8 l
which was clearly high. Some studies suggest that$ s/ {. W# w; L! {8 H! ]0 z
dermal conversion of testosterone to dihydrotestos-
! N1 c6 k7 H7 M: lterone, which is a more potent metabolite, is more! J# b3 @6 M% o- r4 b
active in young children exposed to testosterone
J9 ]) I" Z0 R: ?& fexogenously7; however, we did not measure a dihy-
' _# U6 V0 @8 T Hdrotestosterone level in our patient. In addition to9 Q7 y! @2 N- D0 V X7 W
virilization, exposure to exogenous testosterone in; Z' O$ l; D' W' R' S
children results in an increase in growth velocity and
a1 H6 \9 _6 Zadvanced bone age, as seen in our patient.6 B) z4 ^" V$ S' u8 ]/ } s% n- U
The long-term effect of androgen exposure during
. \+ r1 Z, \2 C, y6 ~) O4 Xearly childhood on pubertal development and final8 o2 f" P9 [) u/ R" H* F
adult height are not fully known and always remain
1 B! ^8 \+ j0 J; T6 ?a concern. Children treated with short-term testos-
+ d) i4 w% l9 y! {' P0 Kterone injection or topical androgen may exhibit some" U B- R" h1 Q" X5 \
acceleration of the skeletal maturation; however, after* L2 c4 s0 W) ]5 Y# W# H
cessation of treatment, the rate of bone maturation
! @9 ]% @4 b. S$ b. G, ndecelerates and gradually returns to normal.8,96 F9 z0 y9 z+ W% l1 {" u/ T* U: r/ i
There are conflicting reports and controversy# D; g- R9 d$ O
over the effect of early androgen exposure on adult
. C/ J- S5 p) U4 Ipenile length.10,11 Some reports suggest subnormal2 Q( P4 }1 q4 _$ F9 V
adult penile length, apparently because of downreg-% h5 q/ W3 D/ \
ulation of androgen receptor number.10,12 However,) x! O/ G! A1 J l
Sutherland et al13 did not find a correlation between
1 s: i e' r( a6 rchildhood testosterone exposure and reduced adult* ]; I7 t3 e# F7 y) j
penile length in clinical studies.; s! x* a* E5 L
Nonetheless, we do not believe our patient is
; ]! _& i6 L: X( S; S+ Rgoing to experience any of the untoward effects from
9 q/ Y6 U# }3 j# Otestosterone exposure as mentioned earlier because; K. T' R2 Q, s+ j$ Z
the exposure was not for a prolonged period of time.: w# R0 w" ~, c W7 o! ~( V- i- h" s
Although the bone age was advanced at the time of
& N* ^6 y+ t& ?. H# D* sdiagnosis, the child had a normal growth velocity at
& h9 M& W9 i& g. G9 S) hthe follow-up visit. It is hoped that his final adult
, Z/ I1 p2 y5 z( z7 }7 A! J$ T Lheight will not be affected.2 n. t. Y8 _. r9 o/ C
Although rarely reported, the widespread avail-
' a3 z) d0 S3 y# j( S: v# Oability of androgen products in our society may3 T# Z/ _, r8 Z# P: O
indeed cause more virilization in male or female; H/ a4 ^ `; O) x$ f& p
children than one would realize. Exposure to andro-. U# E6 F1 ? ?7 _) T+ @
gen products must be considered and specific ques-
/ b T! [( g" xtioning about the use of a testosterone product or
6 {2 g# m; [% ~1 N; k4 ngel should be asked of the family members during
* }# I% e: r& o; }the evaluation of any children who present with vir-
# I* b$ |3 H" q) a! cilization or peripheral precocious puberty. The diag-0 p9 M! m7 l: q" H7 _& W
nosis can be established by just a few tests and by& _: B; m% s) A2 X& X# s- f
appropriate history. The inability to obtain such a
* [6 }0 o x0 ?, f. lhistory, or failure to ask the specific questions, may
! K) U' I' x, {result in extensive, unnecessary, and expensive8 ^/ X6 N& x5 o3 u6 n# A7 p
investigation. The primary care physician should be
6 F3 U$ _; s; C. `$ N/ N% z9 Haware of this fact, because most of these children
/ G8 |& r. ?: L2 {; tmay initially present in their practice. The Physicians’) U3 ~- d y! }7 u' d* u* m: Q
Desk Reference and package insert should also put a
% l4 _$ V3 L; a0 r2 Rwarning about the virilizing effect on a male or
9 m3 z0 \. r, A) }- P1 bfemale child who might come in contact with some-
; @4 A n7 ~ Z/ X% A* N4 {one using any of these products.' X9 g/ [3 P* F$ X5 e
References
" C2 m( m2 I* q2 J. W1. Styne DM. The testes: disorder of sexual differentiation
, Q9 O$ X2 \* Q2 ~5 pand puberty in the male. In: Sperling MA, ed. Pediatric. B. V9 D+ i9 {; S* J
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 I! L) I, `! o# S2002: 565-628.( |; P+ x. p' l3 e+ ^- I' Z( M
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 y3 x% \: r: t% K, F# `3 Q" @
puberty in children with tumours of the suprasellar pineal |
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