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Sexual Precocity in a 16-Month-Old$ H. H1 }& f6 p: ?4 ^* x8 Z v
Boy Induced by Indirect Topical( a* @% j, \. w B! m+ v
Exposure to Testosterone' e7 S, M1 I# X
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 r8 f# M5 E0 X) ]: u5 x% U5 uand Kenneth R. Rettig, MD1
( \) F7 `# P% R( i2 d2 }6 |. Y4 R2 wClinical Pediatrics/ ~ e3 m. ]; S3 ]7 N, m
Volume 46 Number 6
- K' i# L2 v" V6 E( K. G+ _. yJuly 2007 540-543: E5 }0 O" z6 {" i
© 2007 Sage Publications `1 Q4 `# }8 w4 v
10.1177/0009922806296651* v/ [ b" Q6 [7 l }0 N
http://clp.sagepub.com9 h8 F9 L5 L& p8 q/ v& u; y4 y
hosted at
; l; O% z6 [$ B3 Shttp://online.sagepub.com8 g. M1 x7 g7 F1 B
Precocious puberty in boys, central or peripheral,
( N0 F- |1 d2 |7 ais a significant concern for physicians. Central3 W* b, X- r( E' V& D; a8 y$ r
precocious puberty (CPP), which is mediated# p) H% p7 G U7 Q$ e* y4 C
through the hypothalamic pituitary gonadal axis, has
2 h' l. Z# ]& ya higher incidence of organic central nervous system7 l; ^. q" n h/ o, {( y
lesions in boys.1,2 Virilization in boys, as manifested
, W( x y8 Y. |- |+ i3 H1 s) Rby enlargement of the penis, development of pubic
0 ]5 B7 j& U9 ~) Mhair, and facial acne without enlargement of testi-$ s6 U) @% X; r# S# x
cles, suggests peripheral or pseudopuberty.1-3 We4 O6 k# K7 t2 I3 h2 w' ? o
report a 16-month-old boy who presented with the- u7 }* J% ]4 V$ K1 C
enlargement of the phallus and pubic hair develop-
4 W' W7 c V+ [$ vment without testicular enlargement, which was due8 u+ q% x6 `# A, f$ V
to the unintentional exposure to androgen gel used by/ y- k2 O- h# {$ q! c( J; T- S( B
the father. The family initially concealed this infor-$ H0 F% b8 s9 c
mation, resulting in an extensive work-up for this
' w$ A P) K2 V$ b5 h; x% n0 bchild. Given the widespread and easy availability of
1 f7 N1 e |4 Xtestosterone gel and cream, we believe this is proba-. s' K/ e5 o6 H
bly more common than the rare case report in the
8 [: v5 t; Q' a V/ v wliterature.4
& ]! f K3 _* |Patient Report# U# Z; y$ I: B5 v
A 16-month-old white child was referred to the
! w( s2 h% ]' J$ `; l1 r4 R7 Hendocrine clinic by his pediatrician with the concern3 b# d! N0 t2 M/ u ]
of early sexual development. His mother noticed3 x8 x; | q% G! g9 W
light colored pubic hair development when he was
4 Z0 z- r( V; j# @& D5 lFrom the 1Division of Pediatric Endocrinology, 2University of! P3 G2 T0 R* q
South Alabama Medical Center, Mobile, Alabama.$ D1 ~+ H- ~9 @% c9 E
Address correspondence to: Samar K. Bhowmick, MD, FACE,5 h _$ ?1 X! a: E ~1 [4 F5 l
Professor of Pediatrics, University of South Alabama, College of
x P% w- P: m9 }Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 x( u( c& h" q4 |$ P3 s0 Re-mail: [email protected].4 k# u6 A9 K9 \7 L e/ s
about 6 to 7 months old, which progressively became
; g/ a! ^" ?7 [darker. She was also concerned about the enlarge-( E. c% n& t1 O, J5 ~7 o
ment of his penis and frequent erections. The child
. J, Y" J( e9 B5 e# R/ awas the product of a full-term normal delivery, with
! z! h/ Q& o8 f. Qa birth weight of 7 lb 14 oz, and birth length of
9 U5 N' J6 K" Y; H# u20 inches. He was breast-fed throughout the first year' H$ u% U% ^7 S
of life and was still receiving breast milk along with
4 W: C/ R) {( D2 tsolid food. He had no hospitalizations or surgery,$ \8 t/ y, X( ?2 \
and his psychosocial and psychomotor development
7 f% ?9 S4 m2 twas age appropriate.3 Q. @: w: G8 b# c' J
The family history was remarkable for the father,) P6 I/ M6 A' q1 [
who was diagnosed with hypothyroidism at age 16,1 @" l: Q9 E& {4 V
which was treated with thyroxine. The father’s
& |; H% M2 h; w8 j lheight was 6 feet, and he went through a somewhat1 k7 ^% E. Z0 A3 k
early puberty and had stopped growing by age 14.# i% V& @; H3 A( S5 ?
The father denied taking any other medication. The
0 C6 { m8 x0 z9 W0 @* g! wchild’s mother was in good health. Her menarche
. z' E0 i& V: ~$ i$ r. Pwas at 11 years of age, and her height was at 5 feet L$ Q% t. a5 T, n
5 inches. There was no other family history of pre-0 [' Q, i5 J z
cocious sexual development in the first-degree rela-8 |6 e. n& m& }5 b: A7 u- _/ S
tives. There were no siblings.$ Z7 H3 ]2 h* U0 @/ X. J2 A
Physical Examination% x$ ?8 z! W' E; C
The physical examination revealed a very active,
/ S \1 W M5 \1 S7 x4 tplayful, and healthy boy. The vital signs documented" s J& b, N- X6 C: M$ {( I" J* m l: Q
a blood pressure of 85/50 mm Hg, his length was
& r# D& x1 g. r( V" U# `/ @2 c90 cm (>97th percentile), and his weight was 14.4 kg
+ F5 Y+ j7 h$ j/ o' P( J1 W6 Y(also >97th percentile). The observed yearly growth
# {! G: }- v! f6 zvelocity was 30 cm (12 inches). The examination of. v. Y" ?+ b9 Y( @2 c4 ]' K# \2 J
the neck revealed no thyroid enlargement.! G! c! l! b( H9 y* a
The genitourinary examination was remarkable for
7 x% _ t" t4 ` L9 ienlargement of the penis, with a stretched length of4 D8 b. R8 E$ F' y y- `
8 cm and a width of 2 cm. The glans penis was very well! W* \! K7 |, j. w
developed. The pubic hair was Tanner II, mostly around
, @4 e+ P4 F# C/ B0 e540
6 u* a! H* n" D3 aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
n, [. u" ?3 Q, ?$ y. a3 pthe base of the phallus and was dark and curled. The3 B" d; n) V; V2 u' v
testicular volume was prepubertal at 2 mL each.
* U1 q4 G- |+ v2 F' N2 ZThe skin was moist and smooth and somewhat( J& U" [6 M& @& m, p
oily. No axillary hair was noted. There were no
W' ~' q, R, X- U/ l+ B1 Z. C- Iabnormal skin pigmentations or café-au-lait spots.
9 k- F7 C- y; k) V C# k. T4 V, wNeurologic evaluation showed deep tendon reflex 2+
; c/ L& X4 w# ^4 f9 ubilateral and symmetrical. There was no suggestion, s9 R: c4 e7 |* U/ ^8 p7 }
of papilledema.' Q( V: g+ q9 x8 A$ k2 @0 V, G! \
Laboratory Evaluation( x2 k+ }1 ~8 V$ |! f
The bone age was consistent with 28 months by' C3 p0 H" W% D7 Q: N$ `/ {
using the standard of Greulich and Pyle at a chrono-
2 O& O1 U% K: ^( J- alogic age of 16 months (advanced).5 Chromosomal
7 `) D" j5 A# q* Gkaryotype was 46XY. The thyroid function test1 ~3 ?+ ]" u& _: Q
showed a free T4 of 1.69 ng/dL, and thyroid stimu-5 j$ n X, q1 V& ?
lating hormone level was 1.3 µIU/mL (both normal).
9 e' ~/ J& b: \" L) d, _( N5 ~( fThe concentrations of serum electrolytes, blood
9 @5 f5 Z, }# L* s6 d3 ~1 C c5 kurea nitrogen, creatinine, and calcium all were# f7 p- r" G0 T9 a: U6 m0 u! V
within normal range for his age. The concentration `: B; ]$ W& _* }" v6 B3 {
of serum 17-hydroxyprogesterone was 16 ng/dL
4 L+ @4 J# }7 w4 Y* k(normal, 3 to 90 ng/dL), androstenedione was 20
% Z2 ]' j9 ]# s5 qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 r% ^& g; q, r' A- B2 I7 b* G
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
x: X! m0 b) d3 Z, ?2 R; F2 V$ Jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to" ~. k3 |9 D! m7 [7 @
49ng/dL), 11-desoxycortisol (specific compound S)
F2 h6 S( X% s3 Q* y. g' p' }1 [1 z- ~was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 j) m) D; Y* }! ]+ e0 N- r8 f
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% w% Z& I: h$ V% Y9 j7 G7 Stestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! t' N* S) K* G$ o& X2 y( ~and β-human chorionic gonadotropin was less than) @& g+ f o' j
5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ [% U; W. k/ Xstimulating hormone and leuteinizing hormone
: O6 P i& L* Y0 {* X4 W$ {concentrations were less than 0.05 mIU/mL
" l4 P* x* T4 N1 I) ^" b1 Q' V(prepubertal).. n9 P- r0 A( T' m
The parents were notified about the laboratory
k1 A: `: S" u% M- y2 C' L8 Kresults and were informed that all of the tests were% h6 A% W2 O" Z8 W C8 Q2 t) @1 ~
normal except the testosterone level was high. The
0 x& r1 g+ G) cfollow-up visit was arranged within a few weeks to% p4 q) w0 l0 U1 q% |
obtain testicular and abdominal sonograms; how-, y- T& V% o3 f* q: D
ever, the family did not return for 4 months.
# c/ r1 E- J1 fPhysical examination at this time revealed that the
4 M- v5 P( {1 d. Q. lchild had grown 2.5 cm in 4 months and had gained
7 C) v( V) p- a' _5 u a2 kg of weight. Physical examination remained0 G! U, W* ?2 X$ h
unchanged. Surprisingly, the pubic hair almost com-: }, h' ]6 ^$ p, R0 }
pletely disappeared except for a few vellous hairs at
7 }8 T D2 r8 M8 j3 c* K8 bthe base of the phallus. Testicular volume was still 2! }* I5 I$ F3 ~9 C Z% F
mL, and the size of the penis remained unchanged.
2 n$ g. w0 b7 t& d1 N' I& IThe mother also said that the boy was no longer hav-* |! s5 X: n, @
ing frequent erections.2 n" q) r% k/ x- R; [
Both parents were again questioned about use of4 o( v5 s5 g% L8 W/ [9 M# A4 _
any ointment/creams that they may have applied to
7 T3 K* p, S! o" Sthe child’s skin. This time the father admitted the) `+ Q" T' }* E3 h) g
Topical Testosterone Exposure / Bhowmick et al 541
$ f# h5 R- C3 }2 E8 nuse of testosterone gel twice daily that he was apply-
# T6 h2 y" P' l) r+ J' P* Uing over his own shoulders, chest, and back area for9 a c! J( y% f% Y; F7 A
a year. The father also revealed he was embarrassed
, J: |* G1 _7 i8 _' d' s" G$ Jto disclose that he was using a testosterone gel pre-
# W8 |' y6 K' t5 `1 v$ A rscribed by his family physician for decreased libido
+ _3 v. W! |4 k: X+ {/ usecondary to depression.
5 r1 D- ~/ p4 a* V, U0 o3 w: aThe child slept in the same bed with parents.
4 p# d" _6 ?& G9 k- C1 u2 GThe father would hug the baby and hold him on his8 S, n( |7 e0 {
chest for a considerable period of time, causing sig-9 s! j2 A* s: ~! q
nificant bare skin contact between baby and father., l; h6 P/ a" Z3 W8 }
The father also admitted that after the phone call," `6 p1 O- O9 \1 X
when he learned the testosterone level in the baby2 u1 J" J, Z8 n5 i
was high, he then read the product information4 A7 K G- M8 B( n, n* v' C
packet and concluded that it was most likely the rea-; T7 X5 K" s* I4 r, T1 ]
son for the child’s virilization. At that time, they
Z3 T! w1 o; N; P: \# Hdecided to put the baby in a separate bed, and the
4 h$ W7 }6 p5 rfather was not hugging him with bare skin and had
0 J6 D* g3 M! G4 x1 ybeen using protective clothing. A repeat testosterone
2 b: u) z4 N' Q8 F# htest was ordered, but the family did not go to the
1 C7 c" h6 e; ilaboratory to obtain the test.6 i1 g0 [' X8 r9 o2 d
Discussion. q/ l6 Y$ w# }: E
Precocious puberty in boys is defined as secondary
( M& ]9 L+ g. I/ Tsexual development before 9 years of age.1,4
8 u( X) j9 S/ A& x8 s; WPrecocious puberty is termed as central (true) when9 K3 y* K3 g8 v5 K" ]8 c
it is caused by the premature activation of hypo-) o; k1 p1 n: G9 X
thalamic pituitary gonadal axis. CPP is more com-. y5 a" g7 O: b1 A2 b' m
mon in girls than in boys.1,3 Most boys with CPP
, _8 @0 w1 V! Q. G3 p1 ~, a6 ?may have a central nervous system lesion that is
! R: R" a0 c! N: u4 d& cresponsible for the early activation of the hypothal-; v% D: P. }! K
amic pituitary gonadal axis.1-3 Thus, greater empha- Q" t j, R# K+ T- Z0 r
sis has been given to neuroradiologic imaging in6 P' W9 R* {2 @! Z
boys with precocious puberty. In addition to viril-4 S- L f* w; j# ~* }- t1 |9 a9 @4 z
ization, the clinical hallmark of CPP is the symmet-
+ i* p9 `* A2 b" K7 L% P0 [rical testicular growth secondary to stimulation by
0 Y6 y, i4 X3 I* \! S) D3 tgonadotropins.1,3
( N7 j" n3 Z# D) o6 tGonadotropin-independent peripheral preco-
& C7 b! a" K* q7 }9 Ecious puberty in boys also results from inappropriate" O: }! f: l h
androgenic stimulation from either endogenous or3 Y+ m7 L* m' ?0 q: c K+ I! B, j% T
exogenous sources, nonpituitary gonadotropin stim-/ m% {& J7 C4 r3 O
ulation, and rare activating mutations.3 Virilizing
" D; W' u& x( N$ Hcongenital adrenal hyperplasia producing excessive: c# q7 k! r( Q9 I1 q
adrenal androgens is a common cause of precocious8 |( \) x6 `( x
puberty in boys.3,4& M3 ]; g R/ x' E. ]
The most common form of congenital adrenal* c& y5 M' J- _6 C+ A& P! I9 g3 @
hyperplasia is the 21-hydroxylase enzyme deficiency.) \0 M0 I- u; O! w5 L2 X
The 11-β hydroxylase deficiency may also result in
3 W9 K) R$ A, B- \9 J$ [; Vexcessive adrenal androgen production, and rarely,
' w% j. ` a9 a! N# Wan adrenal tumor may also cause adrenal androgen
# X0 [% r' B/ R$ w: [) O% B* Rexcess.1,3
7 u( N% V; ^' {! ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) D6 Y: d2 I7 k1 D: f542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; W9 X/ m) L. D- V# a7 Y
A unique entity of male-limited gonadotropin-4 V# U) Y4 s' A/ j% D
independent precocious puberty, which is also known, G5 ]8 W, a2 l; z" Z
as testotoxicosis, may cause precocious puberty at a
3 B3 E& ~9 \! r! ?very young age. The physical findings in these boys
M9 [9 V0 r5 R. {4 h( ewith this disorder are full pubertal development,% i y' l& p( q% ~
including bilateral testicular growth, similar to boys y- _4 g) y0 e, P& h5 B6 K* ]
with CPP. The gonadotropin levels in this disorder
8 [6 E2 t$ W6 X" L( \are suppressed to prepubertal levels and do not show
! g5 K' V/ X- X0 Spubertal response of gonadotropin after gonadotropin-8 R! C1 f) ^, Y, P+ w! L" k' P
releasing hormone stimulation. This is a sex-linked
3 v. S1 F; M B, v5 B& Pautosomal dominant disorder that affects only
' X/ |2 O- w" w& X- o: @& V* `males; therefore, other male members of the family$ W; M" [9 i$ |$ z/ L
may have similar precocious puberty.37 Z' u* Z3 q, J) Q) Z
In our patient, physical examination was incon-
6 z3 G' n1 s" Q" s1 s7 C# ksistent with true precocious puberty since his testi-
. Z r$ i( o' i5 G. h; n% ycles were prepubertal in size. However, testotoxicosis
3 f5 X# g3 Y1 I0 ? e% mwas in the differential diagnosis because his father9 d# I4 P! |, u1 N5 V3 i' O, ]
started puberty somewhat early, and occasionally,
+ i F+ {( w3 @/ V+ ftesticular enlargement is not that evident in the
; n; X6 S* `# Y( d' o! {' Bbeginning of this process.1 In the absence of a neg-
' p4 _' @" L5 K5 u9 Cative initial history of androgen exposure, our
$ R* x; e8 v4 d5 Dbiggest concern was virilizing adrenal hyperplasia,
! w. O1 F9 C- teither 21-hydroxylase deficiency or 11-β hydroxylase% x( \- [- ]* D7 I% r
deficiency. Those diagnoses were excluded by find-( |% f0 `0 S% e
ing the normal level of adrenal steroids.
& Z2 w8 g) y# b3 ?* W6 s' m7 t XThe diagnosis of exogenous androgens was strongly N8 c8 ]; I- Z5 F) s$ k
suspected in a follow-up visit after 4 months because
: w0 O4 h K o; Y1 L8 Sthe physical examination revealed the complete disap-
% w; X" ]- M& W" vpearance of pubic hair, normal growth velocity, and
9 b& p: }' q( [% w1 ~decreased erections. The father admitted using a testos-
! Y8 T; r) k4 ^5 Uterone gel, which he concealed at first visit. He was
* i4 w0 a8 A3 pusing it rather frequently, twice a day. The Physicians’& `5 `0 m8 H: R. W U# v
Desk Reference, or package insert of this product, gel or
8 c- ]2 S& Z- F5 @cream, cautions about dermal testosterone transfer to
1 J# C! `$ h& Y, E' Runprotected females through direct skin exposure.
8 s- y/ X3 M- ~* @" k- h8 [8 ESerum testosterone level was found to be 2 times the$ C4 Q9 T# }" ]1 M+ ~2 j+ L
baseline value in those females who were exposed to
, ~& U+ |4 R( S% y' oeven 15 minutes of direct skin contact with their male
. D) f( z/ Y( Q/ gpartners.6 However, when a shirt covered the applica-
/ o3 _) v$ o8 Z# ^tion site, this testosterone transfer was prevented.2 e# k+ S* u) M+ z6 ^" Y! L
Our patient’s testosterone level was 60 ng/mL," o, ?3 P% s, v9 ?1 e& l; b) @9 p
which was clearly high. Some studies suggest that
! o' c0 E( \8 o4 A- Jdermal conversion of testosterone to dihydrotestos-( _6 R' Q* x8 F# h% b0 u
terone, which is a more potent metabolite, is more
" @5 U0 R" a' l/ }7 Uactive in young children exposed to testosterone# g6 R+ [" p1 a1 J& p- b) F
exogenously7; however, we did not measure a dihy-
+ M8 M* C+ Y2 Y6 r9 Y1 a' Q) u# G& Ydrotestosterone level in our patient. In addition to4 f( Y: D, |( m% W2 ~
virilization, exposure to exogenous testosterone in% Z: p2 e. C$ v( I0 B& A5 R& n
children results in an increase in growth velocity and- {9 v" N5 F) ^( w- `& |
advanced bone age, as seen in our patient.' j- j b* }$ X* U' K
The long-term effect of androgen exposure during
4 x5 V1 j* W( aearly childhood on pubertal development and final V% c- w2 P; k4 ^
adult height are not fully known and always remain' q6 U& m/ _( D1 A- W* r
a concern. Children treated with short-term testos-
' P- v' j, f) O3 C3 b; c; K7 Kterone injection or topical androgen may exhibit some: F: a- A, O+ E: a. Q' _
acceleration of the skeletal maturation; however, after6 B/ R* A! f0 r* B2 g
cessation of treatment, the rate of bone maturation
$ {6 K) Y7 j% Z b) `5 ^decelerates and gradually returns to normal.8,9
# |2 L3 x7 L e/ _There are conflicting reports and controversy: n# `8 Z: C2 T& Z1 C* S# Q" h/ `
over the effect of early androgen exposure on adult; Y- v( b8 @+ n. o! u8 T+ h
penile length.10,11 Some reports suggest subnormal
1 t( I% M6 q8 f3 Gadult penile length, apparently because of downreg-9 Z# V) b n0 p9 J8 E4 L
ulation of androgen receptor number.10,12 However,$ v3 ]# R# W3 G$ d
Sutherland et al13 did not find a correlation between
* O3 L% q2 T) Wchildhood testosterone exposure and reduced adult
0 B9 S i- o t1 k d: P1 ypenile length in clinical studies.& n6 w% H! x+ f- J. Z" Z$ U6 A/ K
Nonetheless, we do not believe our patient is
. E$ v' A# s x& J: W+ mgoing to experience any of the untoward effects from9 {- e9 H, r' D/ U: x, E
testosterone exposure as mentioned earlier because6 ]: D. @2 ?* |, v
the exposure was not for a prolonged period of time.: h- `" E. j4 B; F9 j6 a
Although the bone age was advanced at the time of
2 c4 W9 f. Z) [ p# f6 Zdiagnosis, the child had a normal growth velocity at, c! U: |! o! ]1 ^( o6 `
the follow-up visit. It is hoped that his final adult
) v. Z/ {, B: d' G4 G$ d6 [height will not be affected.
/ b( B$ s, \4 L+ yAlthough rarely reported, the widespread avail-* [0 |3 \9 x0 U: ^ Z0 ?+ g+ T/ K5 u
ability of androgen products in our society may
* a0 x2 {' o9 zindeed cause more virilization in male or female
9 l* g$ t( {: K! C& wchildren than one would realize. Exposure to andro-/ D7 K+ z: v( L; `" }7 s
gen products must be considered and specific ques-( {- A' Z$ y) }! b9 U
tioning about the use of a testosterone product or" }! [2 N W, E5 X& g
gel should be asked of the family members during! v! W! b# |( E7 j
the evaluation of any children who present with vir-% b! h/ M' P$ j- N
ilization or peripheral precocious puberty. The diag-
6 v: s, b& [9 O7 F" V* ~nosis can be established by just a few tests and by
, R0 _$ ]0 s8 u# ~+ Q% i4 [appropriate history. The inability to obtain such a
\2 d' M# m% S+ x! R* hhistory, or failure to ask the specific questions, may
4 k, r; u2 ~# o3 u% Hresult in extensive, unnecessary, and expensive( C# j/ X n# q+ [
investigation. The primary care physician should be
6 [: L" X7 D' u' L! {aware of this fact, because most of these children0 {4 g. G$ Z- o7 P5 G$ Q- K
may initially present in their practice. The Physicians’1 y2 y7 b/ h* j$ G7 k8 ~
Desk Reference and package insert should also put a7 n8 V; f# N9 l) R# h
warning about the virilizing effect on a male or
5 {: x( q' k6 m0 u0 q! dfemale child who might come in contact with some-/ O7 P" y7 I# K/ H7 w0 g, }) x4 m
one using any of these products.
6 {/ T$ [8 R; x4 P# k9 rReferences
8 t: c1 s4 J- U ^& k" g' N- r1. Styne DM. The testes: disorder of sexual differentiation& s# p3 Y, U3 Y+ `$ U
and puberty in the male. In: Sperling MA, ed. Pediatric
. ]% R2 K: s* i7 j ^5 A' @Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! L/ y+ \0 B1 o2002: 565-628.
; L# `% ]( u' Y# m2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, h( |: @3 Y7 B1 spuberty in children with tumours of the suprasellar pineal |
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