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Sexual Precocity in a 16-Month-Old
. Q4 r: O$ J4 L2 H( j! bBoy Induced by Indirect Topical
$ f/ M9 x8 I, v- [; CExposure to Testosterone
0 o8 g7 S# N$ a; VSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
, s U z- x/ Z+ R/ j: M5 wand Kenneth R. Rettig, MD1/ j- f: ^. @# p1 c; \
Clinical Pediatrics: U9 A3 A4 z( C
Volume 46 Number 6
" v) W/ f! |9 g. AJuly 2007 540-543; r( q9 i: Y+ n
© 2007 Sage Publications R: [# Y3 `- p' H, L# b( p
10.1177/0009922806296651& X* d% |8 ?# I; ?9 E7 v
http://clp.sagepub.com
D5 s) O M: {1 n; e9 Rhosted at$ f0 Y- F) |7 u' f4 o, }5 l+ E
http://online.sagepub.com0 Y% j" O: Q. Y: B
Precocious puberty in boys, central or peripheral,
2 N3 d: {: l0 N& f, j! eis a significant concern for physicians. Central5 f9 c( S8 C; U" n
precocious puberty (CPP), which is mediated; V J2 O+ G0 C3 Q& F
through the hypothalamic pituitary gonadal axis, has' P/ F) c' u1 z0 Q1 U9 R
a higher incidence of organic central nervous system( s& I8 w/ w; E4 W
lesions in boys.1,2 Virilization in boys, as manifested2 X- J0 O4 X1 g, I; l% T$ B
by enlargement of the penis, development of pubic
* a* T* K" X0 u, z( r+ h1 vhair, and facial acne without enlargement of testi-4 Y/ p' f% _0 e% C& }. H" \
cles, suggests peripheral or pseudopuberty.1-3 We1 r0 z9 R% O2 X( f- \
report a 16-month-old boy who presented with the
3 E6 R2 K6 E' t, Menlargement of the phallus and pubic hair develop-5 M: |, x" j) p
ment without testicular enlargement, which was due
6 b i6 R* }/ V0 [to the unintentional exposure to androgen gel used by
% k g; \( r$ H5 T, D2 `7 Xthe father. The family initially concealed this infor-8 ?1 A+ H# }- j7 ^/ |
mation, resulting in an extensive work-up for this
% l( Q7 G# L, j. bchild. Given the widespread and easy availability of
" i9 n. Z4 m: W2 h1 H/ ~4 otestosterone gel and cream, we believe this is proba-6 O7 F3 H, J: y
bly more common than the rare case report in the
9 s* N- W2 b) Fliterature.4) R$ E6 q H( M! E% ], \1 Z
Patient Report
) d/ f6 m% T0 R9 o/ ?5 f4 b* j2 pA 16-month-old white child was referred to the4 f$ f: H, Y1 i' [1 P
endocrine clinic by his pediatrician with the concern. _$ B4 U9 o8 C- m3 @
of early sexual development. His mother noticed$ p4 _6 e/ P: W' u3 a
light colored pubic hair development when he was
3 ]7 o; C" Z3 w& ?& d9 ]From the 1Division of Pediatric Endocrinology, 2University of9 u2 N& X* E2 O$ L4 H- q
South Alabama Medical Center, Mobile, Alabama.
2 c4 F4 v: L: b2 A" p% {0 ~: IAddress correspondence to: Samar K. Bhowmick, MD, FACE,+ p$ \8 i6 v2 r& g2 H+ l1 e
Professor of Pediatrics, University of South Alabama, College of
0 h$ \0 V+ ?- z' Z/ P/ c0 vMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- k2 O; g0 @" Y% Oe-mail: [email protected].
) j' G2 m& A1 a0 X, U0 c6 `about 6 to 7 months old, which progressively became3 K) o+ \$ x+ M" O2 X
darker. She was also concerned about the enlarge-& ]3 p3 t( K, ?; u/ T% H
ment of his penis and frequent erections. The child
7 X" x. ^9 h* i1 R3 r2 j/ uwas the product of a full-term normal delivery, with+ B: Q7 Q3 ~4 ?# n9 y
a birth weight of 7 lb 14 oz, and birth length of: D' ^8 \7 [, Y7 l+ G
20 inches. He was breast-fed throughout the first year
7 ^8 P1 [' ?+ n' xof life and was still receiving breast milk along with. h t% W. n/ _, X
solid food. He had no hospitalizations or surgery,9 Z2 _0 O0 h4 f1 R, G
and his psychosocial and psychomotor development, \+ j5 @" u9 ~9 D5 k j% x
was age appropriate.
* h' {, r$ [& [3 m- X( R7 [The family history was remarkable for the father,
$ K0 E: A U; u5 r: Q' rwho was diagnosed with hypothyroidism at age 16,
$ `; p1 {( K4 l. Qwhich was treated with thyroxine. The father’s# e5 H" H0 `& m! X
height was 6 feet, and he went through a somewhat
* n# y7 a" o! y6 U* E/ uearly puberty and had stopped growing by age 14.2 {' b/ {# N6 Z+ q& G
The father denied taking any other medication. The
8 n1 b# p6 X$ ~' t8 ~- ~+ rchild’s mother was in good health. Her menarche
& [; h! B `( O0 Twas at 11 years of age, and her height was at 5 feet T5 h" [1 Y* Q# K5 N% J, Y9 z
5 inches. There was no other family history of pre-& {' ^( W! \' m" a' j
cocious sexual development in the first-degree rela-
/ v8 t a* U0 N8 M: `tives. There were no siblings./ m8 p& A' Y8 N; ^/ g
Physical Examination
: [1 y7 X' V* h0 v/ d7 q' U6 dThe physical examination revealed a very active,, ]4 s- Y7 x, z" Z
playful, and healthy boy. The vital signs documented
. W$ ^! P0 L! da blood pressure of 85/50 mm Hg, his length was
! Q+ |& t7 Q9 C2 `6 N* B- f90 cm (>97th percentile), and his weight was 14.4 kg" r u) g* _2 s$ V
(also >97th percentile). The observed yearly growth
! U c K7 L$ t. X/ xvelocity was 30 cm (12 inches). The examination of3 O. W7 n9 b+ X; s _
the neck revealed no thyroid enlargement.
! Q$ g `) c* ~" p1 d' U, I1 D3 [The genitourinary examination was remarkable for
; Y% j0 z6 j6 [& ^" Z* E$ ?! v4 ^) m+ renlargement of the penis, with a stretched length of
) q! r0 P) f& _' e6 d/ |9 {4 y8 cm and a width of 2 cm. The glans penis was very well' B3 l- W1 K7 F% Y" E
developed. The pubic hair was Tanner II, mostly around
! m( y7 V8 Z9 B5 x540
3 l* \$ L# m& U/ a: Z8 a1 m1 iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& {0 n4 B& a9 Y" I. Wthe base of the phallus and was dark and curled. The0 S2 p; k6 H6 F5 L1 Y3 N
testicular volume was prepubertal at 2 mL each.
& ?/ T ~6 }$ |4 B7 T6 v9 d# VThe skin was moist and smooth and somewhat+ Q; a" t2 O$ p% M! }
oily. No axillary hair was noted. There were no
8 e5 s$ v. ^" Z, u m/ c1 Labnormal skin pigmentations or café-au-lait spots.
) V b9 J4 {! k5 F( iNeurologic evaluation showed deep tendon reflex 2+. ?: ^) r1 G/ o6 S% h; m0 f
bilateral and symmetrical. There was no suggestion! W! a2 `6 ~: X l& O9 s2 \7 r
of papilledema.# E7 b' p0 m0 B2 h! C
Laboratory Evaluation* W: h" ~/ l) \6 r
The bone age was consistent with 28 months by
* l+ D0 i" v0 Uusing the standard of Greulich and Pyle at a chrono-
- S2 {5 X7 c$ @3 G1 Jlogic age of 16 months (advanced).5 Chromosomal5 {; f: l. \( n4 _$ @4 g2 B1 c
karyotype was 46XY. The thyroid function test
* n! ?: \7 b3 S- @* M! u$ X* i$ ~showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ U/ w. V" h6 f
lating hormone level was 1.3 µIU/mL (both normal).
* H) H' a# h9 V1 O9 n0 `The concentrations of serum electrolytes, blood
2 [$ h; b2 e9 e, R. b r4 J, n. b* S' Furea nitrogen, creatinine, and calcium all were! X2 o# C2 {) a9 o; x
within normal range for his age. The concentration/ Y. b' V: h" v, r
of serum 17-hydroxyprogesterone was 16 ng/dL
$ f" v- C5 J8 s0 \: ]2 h0 H(normal, 3 to 90 ng/dL), androstenedione was 20( W @% n# F m2 ^: S& W$ A* E
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ r; L5 R3 q Yterone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 g" [$ Q/ v+ K( o$ ]1 t# f3 }desoxycorticosterone was 4.3 ng/dL (normal, 7 to9 L- H+ N+ h5 @, l
49ng/dL), 11-desoxycortisol (specific compound S)
4 [6 c4 y% R; qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) E; {/ B$ m! |6 d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total8 v' f' R+ I; P, ?; T- B. t
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),( F- B. u8 P: y& k# T8 {
and β-human chorionic gonadotropin was less than4 A; o1 F# s" ]5 g" W
5 mIU/mL (normal <5 mIU/mL). Serum follicular
4 O$ D) d2 ` a Q' Astimulating hormone and leuteinizing hormone: ?" f7 f% y; T$ V6 Q' f/ _2 p
concentrations were less than 0.05 mIU/mL3 n9 s0 b+ K) h: [7 x
(prepubertal).
( `, K& ]/ ~% d/ j* |2 oThe parents were notified about the laboratory/ I+ t4 L! \/ l: p
results and were informed that all of the tests were5 F* S% ~" l( k, w, \6 ^' B5 R
normal except the testosterone level was high. The
& U; L8 }( }# Xfollow-up visit was arranged within a few weeks to
% f, \+ i# A7 `0 ]1 Pobtain testicular and abdominal sonograms; how-: O# Y( b0 t! b) E, y7 z' Y
ever, the family did not return for 4 months.
6 I/ l$ w9 F- L5 H2 S5 F" a: [Physical examination at this time revealed that the
) y% l, Q/ o2 s' zchild had grown 2.5 cm in 4 months and had gained% z; E, Y4 \* M, q s
2 kg of weight. Physical examination remained
! C9 l4 u2 H. Z$ e2 h2 W: e9 Ounchanged. Surprisingly, the pubic hair almost com-
% A" U* @. `7 A( w3 j! dpletely disappeared except for a few vellous hairs at$ w: }$ A' F* B! e; H; H
the base of the phallus. Testicular volume was still 2! o8 O% D5 o! }( s) a: B* E
mL, and the size of the penis remained unchanged.+ G! _; Q" I" ^7 }! s( P
The mother also said that the boy was no longer hav-: U1 G2 L% B* j
ing frequent erections.$ y, K: T1 M9 e0 A, P1 Q9 ]
Both parents were again questioned about use of
) s8 B E3 O9 z/ D9 W8 y5 bany ointment/creams that they may have applied to
4 `/ ]$ O7 m4 L# I \! N" Jthe child’s skin. This time the father admitted the) V' w* s& t5 M+ G
Topical Testosterone Exposure / Bhowmick et al 541
( C7 Z( Y; m- z. Z1 \' I" ?6 xuse of testosterone gel twice daily that he was apply-8 F7 t% u7 E% q- m
ing over his own shoulders, chest, and back area for5 b) f0 E! I, R( p( Y: M1 K" x2 X
a year. The father also revealed he was embarrassed- @0 z& b9 k9 s8 `* h* _ J
to disclose that he was using a testosterone gel pre-
- Q! f0 G" K9 X, u, E' Y" R3 jscribed by his family physician for decreased libido/ {5 @1 z% R5 [: ^
secondary to depression.
+ |5 q X5 |9 I. O7 DThe child slept in the same bed with parents." A/ v1 ?. b+ z4 T% j% S
The father would hug the baby and hold him on his
/ u) b6 U' f8 F1 E9 p/ Ychest for a considerable period of time, causing sig-4 P Y6 d+ D( R1 |6 x$ ?* q8 h
nificant bare skin contact between baby and father.- ?2 j/ _9 _8 v1 Z) _% A
The father also admitted that after the phone call,
9 X5 |& h0 b& r/ fwhen he learned the testosterone level in the baby
8 B/ v3 n+ B& E0 N! f$ Jwas high, he then read the product information5 H9 U1 T" {9 e
packet and concluded that it was most likely the rea-& `7 x' \1 N. E7 W4 | Z; L
son for the child’s virilization. At that time, they
% P- s0 a \/ A \decided to put the baby in a separate bed, and the, V0 i. Z5 f+ u; A
father was not hugging him with bare skin and had9 w# t3 ]. D, A
been using protective clothing. A repeat testosterone" [4 S# @6 H. T1 f/ [ j ]
test was ordered, but the family did not go to the; z! w, p' \5 j# N3 }
laboratory to obtain the test.1 W3 o% k- z( S( j8 n
Discussion$ H" C+ r6 _' L ]/ L# G4 [
Precocious puberty in boys is defined as secondary3 {! K, ^; ^9 I# ^, c3 ~
sexual development before 9 years of age.1,4) B2 u3 k2 | D6 g+ H- D
Precocious puberty is termed as central (true) when
& c$ y9 l$ `- z6 |9 w# _it is caused by the premature activation of hypo-
, ^& |3 t' b1 p- ^5 {; i% @thalamic pituitary gonadal axis. CPP is more com-
, i7 j3 t, W. [ u+ imon in girls than in boys.1,3 Most boys with CPP
3 h* q7 ]) W" _may have a central nervous system lesion that is5 W! A# ]0 z3 \8 G
responsible for the early activation of the hypothal-
# e7 L0 r4 g, Mamic pituitary gonadal axis.1-3 Thus, greater empha-
2 H: }8 n* ]/ P f; Q z* {sis has been given to neuroradiologic imaging in# T0 d" r# f# H, H( q
boys with precocious puberty. In addition to viril-
6 t" @3 j+ Y% O5 j! Q. Q0 Sization, the clinical hallmark of CPP is the symmet-& F, a5 {' M1 h9 {! {8 \$ F
rical testicular growth secondary to stimulation by
. c2 y: M C4 r2 A' S5 bgonadotropins.1,3
% p1 A7 V# S& j0 UGonadotropin-independent peripheral preco-2 k- B; i" c7 [0 G
cious puberty in boys also results from inappropriate* F% F3 F, [1 K6 d, L# Y
androgenic stimulation from either endogenous or
1 v( T' B9 r- i- v+ C! Nexogenous sources, nonpituitary gonadotropin stim-
& k# Z# S0 {) Z2 h" L8 `ulation, and rare activating mutations.3 Virilizing: a) q' }3 o' }- A
congenital adrenal hyperplasia producing excessive* o. H- y9 a3 ~/ x" J4 Y8 B
adrenal androgens is a common cause of precocious
, O; G- Z Y2 T- S% Z! Hpuberty in boys.3,4
- K5 t' w& z& w& b. I. BThe most common form of congenital adrenal
9 k* o7 l/ @# @5 J- |" y$ I z: v( Whyperplasia is the 21-hydroxylase enzyme deficiency.; I8 r: N5 B9 E' e) J. d) g+ v
The 11-β hydroxylase deficiency may also result in
8 a- a F+ m6 a7 i& |excessive adrenal androgen production, and rarely,# Z4 X! F- h* u% Y. N5 k8 R, P
an adrenal tumor may also cause adrenal androgen7 q5 p6 b' p# B$ x5 v: C
excess.1,3
" z/ B: n$ ], Q/ Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 Z8 g' z' G3 E) s: j542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; }; ?3 N8 B. a/ \/ \8 E2 @A unique entity of male-limited gonadotropin-
, ^, {1 B) s7 [/ L4 r0 w0 {/ uindependent precocious puberty, which is also known# ~9 S' {$ F$ w) B
as testotoxicosis, may cause precocious puberty at a5 N* n' n9 S, l# D
very young age. The physical findings in these boys+ x) j. @6 c( Y
with this disorder are full pubertal development,
0 a! B3 t5 i3 f( [' ^including bilateral testicular growth, similar to boys
. O) I0 |* e _1 G+ H8 M" L* kwith CPP. The gonadotropin levels in this disorder( y4 B% S: d$ c
are suppressed to prepubertal levels and do not show" d/ p) O9 k# @: P1 x% \
pubertal response of gonadotropin after gonadotropin-
# F/ `8 b) E% L- B9 F3 d( v' ^releasing hormone stimulation. This is a sex-linked) `+ L0 K8 Q8 ]# D5 A
autosomal dominant disorder that affects only: f, h6 s$ y( V3 g
males; therefore, other male members of the family0 |7 [$ l O5 j! |
may have similar precocious puberty.3
& x1 M# f7 }# J% Q7 _! {# \( K4 NIn our patient, physical examination was incon-
, Y5 }3 K# V1 o* M0 Isistent with true precocious puberty since his testi-9 o! `1 b( b8 [3 y0 i& b# P; R
cles were prepubertal in size. However, testotoxicosis
' b" I. i* O7 @0 y% g. f8 I7 Twas in the differential diagnosis because his father
2 m, z/ F! v k$ Zstarted puberty somewhat early, and occasionally,
4 ^7 M. P+ v: t0 k+ J: f+ r9 ^testicular enlargement is not that evident in the/ S$ |( [% z/ w# s' L
beginning of this process.1 In the absence of a neg-
! W9 |* O) O% C+ G6 iative initial history of androgen exposure, our4 R: x1 W0 r# G+ X' N
biggest concern was virilizing adrenal hyperplasia,7 b* ~7 v) K/ _! N# x
either 21-hydroxylase deficiency or 11-β hydroxylase. o: G, X* n6 g4 L/ ]$ n( I
deficiency. Those diagnoses were excluded by find-" }( x( Q% H* l) z
ing the normal level of adrenal steroids.
- w [7 q& w+ k j- z8 rThe diagnosis of exogenous androgens was strongly! T" n$ f$ J; k5 z
suspected in a follow-up visit after 4 months because4 c7 ~* x+ w: w z2 K; c
the physical examination revealed the complete disap-2 ], M" |) ^6 W- L5 K2 q6 L
pearance of pubic hair, normal growth velocity, and% K8 q$ }9 z' E/ u
decreased erections. The father admitted using a testos-
- F& a+ B: w: lterone gel, which he concealed at first visit. He was" G# z9 g# n; M# { @9 c
using it rather frequently, twice a day. The Physicians’$ d% u5 w% G! U A5 F( e% D
Desk Reference, or package insert of this product, gel or
- e# F6 z. a& f/ rcream, cautions about dermal testosterone transfer to
% `% e' L. r! Vunprotected females through direct skin exposure.
) n9 P1 t5 e$ B1 d: PSerum testosterone level was found to be 2 times the
; K! {/ \, s4 q9 f# R( k/ `baseline value in those females who were exposed to
7 p1 ~% y5 s0 N+ f) heven 15 minutes of direct skin contact with their male" T% M' z4 |+ t, o- q' l$ k# J9 N* K
partners.6 However, when a shirt covered the applica-
5 B& T& a& U9 X) Ltion site, this testosterone transfer was prevented." I; C! g! g+ J0 q
Our patient’s testosterone level was 60 ng/mL,) j4 U% H- ?/ o, f( u
which was clearly high. Some studies suggest that$ k) Y( M0 T3 O: w1 }2 Y4 c
dermal conversion of testosterone to dihydrotestos-+ x1 R) \0 i- h C+ w
terone, which is a more potent metabolite, is more' T. W( R& [$ ^) k4 q5 B
active in young children exposed to testosterone
" X# A) S4 a4 s. D" e" r6 M: S) Eexogenously7; however, we did not measure a dihy-' ^; P5 U5 k6 N% e6 C8 `3 m
drotestosterone level in our patient. In addition to
) Q2 N L+ g. I- D4 Q* ?. Pvirilization, exposure to exogenous testosterone in c5 ~, a$ w& A" f9 z
children results in an increase in growth velocity and
) P# Z9 D( u. c2 a2 ?! o1 radvanced bone age, as seen in our patient.
1 @, g: {6 K$ {, l+ bThe long-term effect of androgen exposure during
: k% r6 ?& b( E: kearly childhood on pubertal development and final
S& H0 j7 K! n- p1 Aadult height are not fully known and always remain
/ X9 t9 C) p. G! G% ^; i7 Za concern. Children treated with short-term testos-' x4 \4 F" J& l/ X8 v
terone injection or topical androgen may exhibit some+ m( p1 A7 \, V+ a$ ~% ]
acceleration of the skeletal maturation; however, after
( @1 K$ y0 A w: w; L5 Ecessation of treatment, the rate of bone maturation
/ ` S6 C" t) u% q8 ddecelerates and gradually returns to normal.8,9
; y" I1 R9 L( rThere are conflicting reports and controversy
* X& x% u& T4 J9 r# vover the effect of early androgen exposure on adult2 M A; q ~; V& e" j
penile length.10,11 Some reports suggest subnormal
3 F6 V& C4 k4 u7 u$ J7 L9 Eadult penile length, apparently because of downreg-7 Y6 Z ~$ d* K7 D- a8 c1 _
ulation of androgen receptor number.10,12 However,
7 p: K* ^) v0 b. ISutherland et al13 did not find a correlation between. J! Q& @. a4 g: Y/ R3 c( W
childhood testosterone exposure and reduced adult* |, \+ B) o. S$ S: w/ h
penile length in clinical studies.
6 z$ U+ B! }3 C- ONonetheless, we do not believe our patient is
4 O% {/ K I6 H- Y; w( s& sgoing to experience any of the untoward effects from* o# F2 @- I2 Q. ~' e: g, v# ?
testosterone exposure as mentioned earlier because
5 }# P) [ r% \the exposure was not for a prolonged period of time.
" ]! z: f( v! n0 U7 o! @' ?8 |Although the bone age was advanced at the time of
; p# E$ c6 y( W6 V6 ~3 Z3 ~/ sdiagnosis, the child had a normal growth velocity at
' v9 w2 {5 f+ H- Othe follow-up visit. It is hoped that his final adult
1 o0 p. H, p& E2 @. Wheight will not be affected.
; i5 k9 g9 `8 W, i6 X pAlthough rarely reported, the widespread avail-
k2 x# S; Q) }" R9 }ability of androgen products in our society may; O7 P4 y! ` t$ Q, A- }3 a" q/ p
indeed cause more virilization in male or female$ B; O4 o& P, a- m
children than one would realize. Exposure to andro-3 ^8 N" R- q, Y
gen products must be considered and specific ques-3 j, p" l* w$ e7 ]1 z
tioning about the use of a testosterone product or5 b0 m! \. F2 w) v" m
gel should be asked of the family members during6 N% e& E' {* A/ }% P# R
the evaluation of any children who present with vir-. y. ? j0 P5 ^. H& i; u
ilization or peripheral precocious puberty. The diag-0 {1 a9 R5 g5 \
nosis can be established by just a few tests and by
3 |# O S9 c' e+ ~appropriate history. The inability to obtain such a5 X1 i0 u; ?* a1 S
history, or failure to ask the specific questions, may. L, j! [- v c. s, Z) j& R
result in extensive, unnecessary, and expensive+ X2 D* j$ J& v! J
investigation. The primary care physician should be
! g, Y1 p8 r/ i. U+ f: Kaware of this fact, because most of these children3 K& b9 a2 \7 z" I1 g9 l
may initially present in their practice. The Physicians’
! Q8 p0 h& \0 HDesk Reference and package insert should also put a5 ~1 }9 s" ~! ^$ |% W# M. ?
warning about the virilizing effect on a male or2 h/ @% R! o$ Z4 G* } G _
female child who might come in contact with some-. n0 Y3 A+ i, S1 W
one using any of these products., X. |$ S. j* s
References4 G3 n% L, k3 ~8 C+ w \
1. Styne DM. The testes: disorder of sexual differentiation
5 G0 D+ a2 C9 Uand puberty in the male. In: Sperling MA, ed. Pediatric
3 `: A& s$ m4 w) wEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 _; _4 f9 e( F5 H7 a/ C2002: 565-628.4 x$ H/ N- a* P4 H/ g& A ]
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
E& X# p0 }, r _' d2 P7 q1 ?3 Vpuberty in children with tumours of the suprasellar pineal |
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