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Sexual Precocity in a 16-Month-Old
; Y# r# Y, l% I9 }7 rBoy Induced by Indirect Topical9 o$ n1 ?" a6 x0 I
Exposure to Testosterone
2 v5 Q! L: f, H9 } KSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 l1 |+ h% L/ c( l( m
and Kenneth R. Rettig, MD1$ f; L. ~! V" @& n
Clinical Pediatrics" ^6 h# v- K8 ^0 c5 x r4 S0 X
Volume 46 Number 6
2 `6 G- ^0 d7 K$ t* i9 D' s6 aJuly 2007 540-543$ D0 g# j" {" x6 {
© 2007 Sage Publications
( q8 X: [/ e; B( \7 c5 c" y' C/ N10.1177/0009922806296651+ ^% {7 W7 n6 a, u/ I+ X+ [9 f
http://clp.sagepub.com
1 I$ C" D. g( P. Ohosted at
& m$ p! P7 Q7 `# E2 lhttp://online.sagepub.com
B* s- i+ t8 x, J+ H7 rPrecocious puberty in boys, central or peripheral,- i. K' U7 M# P& M3 Q( g
is a significant concern for physicians. Central
. e, M. n4 l' sprecocious puberty (CPP), which is mediated
9 m( u8 i0 _5 |3 A1 h w7 |through the hypothalamic pituitary gonadal axis, has( o8 A" s+ E; ]0 \9 U
a higher incidence of organic central nervous system6 F% a5 S N" ^
lesions in boys.1,2 Virilization in boys, as manifested
2 t ] y( ?; r2 D7 ]3 M* E3 y$ fby enlargement of the penis, development of pubic
& x1 d# ^# D# l& |+ Nhair, and facial acne without enlargement of testi-* F9 M- ]2 q; ]
cles, suggests peripheral or pseudopuberty.1-3 We- I7 U9 C- u9 D
report a 16-month-old boy who presented with the3 n* u; _5 o/ Q6 d$ j# I
enlargement of the phallus and pubic hair develop-
2 x) [3 p0 j) }1 `* Y) gment without testicular enlargement, which was due* f- Q: u) B5 m- l7 q% `. Z z
to the unintentional exposure to androgen gel used by
( \7 v! E! X6 N9 l4 pthe father. The family initially concealed this infor-
1 e) C4 _4 E8 Q! ^" Rmation, resulting in an extensive work-up for this, V( N1 @; x5 }- v0 D. s" Q5 m
child. Given the widespread and easy availability of3 b8 [! s4 m' A6 `- F7 m/ [$ c
testosterone gel and cream, we believe this is proba-) i) T: p5 {3 n% c8 @" @& l
bly more common than the rare case report in the1 j' l' c5 R: p% u
literature.43 D$ q. u i* ?$ _2 d/ A; \
Patient Report% [, q/ O% s" o/ t/ v
A 16-month-old white child was referred to the
# {, j3 N3 b* gendocrine clinic by his pediatrician with the concern3 b' g4 q/ [3 H
of early sexual development. His mother noticed, t3 q4 @; j) L- g, }. v
light colored pubic hair development when he was
5 X$ U1 L8 G! FFrom the 1Division of Pediatric Endocrinology, 2University of/ j( z" \7 w6 Q6 y" d6 m
South Alabama Medical Center, Mobile, Alabama.6 o5 k2 q5 I# r/ j1 ?4 R
Address correspondence to: Samar K. Bhowmick, MD, FACE,6 @* J0 _6 A2 |8 ^5 P
Professor of Pediatrics, University of South Alabama, College of- B V& V8 M4 o& q& D
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- ?0 z. I. l" ~) l7 g6 u
e-mail: [email protected].
0 f0 z7 ?- j& y( x1 |about 6 to 7 months old, which progressively became8 O9 `3 Y3 T* P2 W
darker. She was also concerned about the enlarge-
/ w/ H' |( {$ S% pment of his penis and frequent erections. The child
3 l* Y7 u& |3 v4 _* d) S. [was the product of a full-term normal delivery, with9 R1 @$ f9 d! K2 c- I5 V
a birth weight of 7 lb 14 oz, and birth length of
0 k* {5 I# [: J9 I. C! [7 j20 inches. He was breast-fed throughout the first year
Q, n% L" g* U7 w- M* }of life and was still receiving breast milk along with
6 d) w% } I4 c& N2 Bsolid food. He had no hospitalizations or surgery,
9 e8 t& b5 I& M% Vand his psychosocial and psychomotor development9 a/ ~( r% ?) o# l& `8 Q
was age appropriate.% @/ ~3 b8 ]( R; z
The family history was remarkable for the father,
3 o. i$ P8 G0 hwho was diagnosed with hypothyroidism at age 16, U% E) ?" n5 r Z
which was treated with thyroxine. The father’s$ W. D( m: M V
height was 6 feet, and he went through a somewhat4 ?. k3 o$ b/ x8 T
early puberty and had stopped growing by age 14." F0 S" ~2 Z p1 X+ r! `' V
The father denied taking any other medication. The
: y d; O$ ?9 dchild’s mother was in good health. Her menarche
: @; J" ^7 e% W, l U7 ^was at 11 years of age, and her height was at 5 feet: i* m$ t' }7 J5 g9 j
5 inches. There was no other family history of pre-
. [6 T3 H; j8 a& dcocious sexual development in the first-degree rela-
) ?1 }- E4 O4 D. l5 h+ Z- P2 Q( otives. There were no siblings.
( P* Z/ v' F6 H5 i7 w, @Physical Examination
* g4 O, N4 U t0 D# ?. U6 }The physical examination revealed a very active,- I# T. a! M. k X$ g
playful, and healthy boy. The vital signs documented
' ^% u) V' X( J9 [3 pa blood pressure of 85/50 mm Hg, his length was
/ y: ?" c6 n8 s4 d- d( ] B90 cm (>97th percentile), and his weight was 14.4 kg
! ^9 d7 F) [) _8 o; Y; B* R$ C(also >97th percentile). The observed yearly growth
9 @0 d* _) _+ K5 P$ \( Ivelocity was 30 cm (12 inches). The examination of
& m. l: ], w! ]: W9 jthe neck revealed no thyroid enlargement.
* R8 z* S& u+ K# VThe genitourinary examination was remarkable for2 m& g _) L w3 I7 B% t4 f2 ?
enlargement of the penis, with a stretched length of! ^ H# e: x5 \, w, K
8 cm and a width of 2 cm. The glans penis was very well
8 @0 Y+ \7 h D( adeveloped. The pubic hair was Tanner II, mostly around. c" u/ l! D& R7 C/ d
540
9 R+ ]( S7 H* A* jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; Z1 @4 [: @& b/ ~the base of the phallus and was dark and curled. The L, Y# j9 |6 ^- t
testicular volume was prepubertal at 2 mL each.
& k2 d6 n7 R( F( O! TThe skin was moist and smooth and somewhat' L* C, e2 w3 V- D/ u
oily. No axillary hair was noted. There were no
) [3 h; E" X; J Uabnormal skin pigmentations or café-au-lait spots.
* z* X8 F8 a6 Z7 g) @3 xNeurologic evaluation showed deep tendon reflex 2+
, L: s# j3 q; R) o( Kbilateral and symmetrical. There was no suggestion
1 j7 z0 t$ C" W" [5 x6 n. E. hof papilledema.: r, m9 H& D t# t" i
Laboratory Evaluation# P, b$ o/ W6 \ W
The bone age was consistent with 28 months by
6 O5 e$ T* G" s" T6 Pusing the standard of Greulich and Pyle at a chrono-
% I1 ]1 P3 U) h9 h# v5 Elogic age of 16 months (advanced).5 Chromosomal* @+ u, a: K/ {& D7 {1 h- d Q( N* B7 H
karyotype was 46XY. The thyroid function test! {9 v1 `9 {/ P" w( i
showed a free T4 of 1.69 ng/dL, and thyroid stimu-# R) ^. t8 n3 Q0 C: A a: P* [
lating hormone level was 1.3 µIU/mL (both normal).' q4 P" }3 Y% P/ b* K, s% h
The concentrations of serum electrolytes, blood" T( q/ R* v2 j! Q
urea nitrogen, creatinine, and calcium all were% V( V0 x" j" X8 D
within normal range for his age. The concentration7 I9 @2 u5 C/ Z) r- D' E
of serum 17-hydroxyprogesterone was 16 ng/dL7 V+ T9 y) H, a8 g
(normal, 3 to 90 ng/dL), androstenedione was 20
8 H; t7 B6 t, Tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* s6 {; ^* O% ?+ z% ~3 E: e
terone was 38 ng/dL (normal, 50 to 760 ng/dL),, u S5 ~9 d1 d9 D
desoxycorticosterone was 4.3 ng/dL (normal, 7 to9 y$ F/ H; L2 k% q$ u
49ng/dL), 11-desoxycortisol (specific compound S)4 k! M" z* Q' ]3 g* p7 ^6 I8 x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 M: G2 L# g3 C4 itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% \- Z4 V$ _8 p& G6 `8 Rtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 ]& V) i- y2 A# b' x& A7 ^7 Dand β-human chorionic gonadotropin was less than
: _8 W/ i+ [$ e, p+ J' `7 H5 mIU/mL (normal <5 mIU/mL). Serum follicular
% J- s5 o/ ^4 M* q, ^stimulating hormone and leuteinizing hormone
6 l) R1 Y9 E/ s5 C% Bconcentrations were less than 0.05 mIU/mL
% [: F8 x y: F; @& R(prepubertal).
" X4 y6 o6 }8 I7 }The parents were notified about the laboratory
4 E; L3 H8 A r5 H' j5 N5 ]& oresults and were informed that all of the tests were
0 T* T) r( D ^/ w" Q2 h% P, z# Jnormal except the testosterone level was high. The
" K, l0 k( Y( B0 Ffollow-up visit was arranged within a few weeks to
3 [% |' G( i9 l# d. nobtain testicular and abdominal sonograms; how-
2 H" B; s/ q, R% a$ D* Fever, the family did not return for 4 months.9 R& a$ W1 T3 ~ L
Physical examination at this time revealed that the$ f/ w& g" g1 Y5 T* e4 n9 C
child had grown 2.5 cm in 4 months and had gained0 m3 b* e K- V+ {4 S
2 kg of weight. Physical examination remained4 q+ H* k( I4 L/ ]% _
unchanged. Surprisingly, the pubic hair almost com-
. K4 c9 z# T% m8 _9 gpletely disappeared except for a few vellous hairs at0 \( T3 ^3 `3 l2 p- z5 u/ u1 o
the base of the phallus. Testicular volume was still 2
; U- G8 E) R8 w8 `mL, and the size of the penis remained unchanged.
$ C7 k" M {, A9 \3 a4 xThe mother also said that the boy was no longer hav- j5 E# ^$ g( U: {
ing frequent erections.
, P; m I* Y$ D2 HBoth parents were again questioned about use of5 \ q5 q4 g9 P
any ointment/creams that they may have applied to
% C" T: V) F$ [2 |9 }* t! }8 kthe child’s skin. This time the father admitted the5 q4 _0 t; V# v! O, {. d0 f
Topical Testosterone Exposure / Bhowmick et al 541
+ ^4 n4 G6 }+ Ause of testosterone gel twice daily that he was apply-2 m0 `7 o+ H' G, ~
ing over his own shoulders, chest, and back area for. I* ^( C* w: L& Q9 l5 ~
a year. The father also revealed he was embarrassed
2 a3 H( h `' y& ?" R6 ]to disclose that he was using a testosterone gel pre-
( ~% M- W1 |; r$ A* }3 D6 qscribed by his family physician for decreased libido
0 X. f6 r" D2 n$ N! j$ Xsecondary to depression.
2 a! E8 n9 r, ^3 LThe child slept in the same bed with parents.; ]& t& m [5 E- I& I8 j
The father would hug the baby and hold him on his
. h3 k8 b' x0 S) Uchest for a considerable period of time, causing sig-0 }0 E& L4 }/ Z) |$ R
nificant bare skin contact between baby and father.% X9 }7 Z, i! O+ X
The father also admitted that after the phone call,
0 {% E' y5 ]: v) P/ Mwhen he learned the testosterone level in the baby( c, r- j1 l, B( M2 w+ f
was high, he then read the product information
/ w; r) G3 H7 p# k8 s. |/ ~" q# Jpacket and concluded that it was most likely the rea-
; `: i1 G6 n2 @; @7 c& T4 q( zson for the child’s virilization. At that time, they
) o, Y. s! I2 ^3 Y4 F# @3 Ldecided to put the baby in a separate bed, and the
2 ]& ^3 {6 ^: \- yfather was not hugging him with bare skin and had
6 ?8 u+ I1 j [% h, ubeen using protective clothing. A repeat testosterone+ f+ Q" A& l) x( e, L, V
test was ordered, but the family did not go to the
, J: H. ~7 x- c. x! c, \( M8 R) ilaboratory to obtain the test.
. {: ?, _5 k' YDiscussion2 K+ ` ]$ h9 H4 S
Precocious puberty in boys is defined as secondary
- q5 A+ f8 k) T( F. U" R' F0 }sexual development before 9 years of age.1,4
- e& }% |" P% NPrecocious puberty is termed as central (true) when+ D4 M" t5 R1 d' R, a. Q
it is caused by the premature activation of hypo-4 O8 z3 {: q0 b; M- j7 X( L
thalamic pituitary gonadal axis. CPP is more com-
) N& Z; P* e& fmon in girls than in boys.1,3 Most boys with CPP$ Y( ?5 G* S' X4 b+ u Y2 R6 n
may have a central nervous system lesion that is
& ^3 M! w( }: W/ D6 N& G6 a/ jresponsible for the early activation of the hypothal-) m, t9 d/ v4 {6 R+ S1 f
amic pituitary gonadal axis.1-3 Thus, greater empha-
9 _. Z. v- c+ _) bsis has been given to neuroradiologic imaging in" ?; K) a: A4 d+ Y: n
boys with precocious puberty. In addition to viril-
, g6 ]4 {( q1 W, |ization, the clinical hallmark of CPP is the symmet-' ^& ~; A9 A$ s v0 G
rical testicular growth secondary to stimulation by/ A) f! ~0 c$ E
gonadotropins.1,3
: X! A+ x4 D: AGonadotropin-independent peripheral preco-
( Q7 X! x9 E; V: Q7 Bcious puberty in boys also results from inappropriate
0 k: _5 f! O% c- w+ Uandrogenic stimulation from either endogenous or
+ y6 X% e# D5 Q- \exogenous sources, nonpituitary gonadotropin stim-: g5 a( J4 ]' j+ ^( P
ulation, and rare activating mutations.3 Virilizing8 `+ G* }5 E- S
congenital adrenal hyperplasia producing excessive5 g' _9 S3 {. E4 o9 g
adrenal androgens is a common cause of precocious
+ h( X5 K$ G( k c' g+ opuberty in boys.3,4
: O0 N! c1 v9 b/ ~5 H% qThe most common form of congenital adrenal' C* G! w- D: p
hyperplasia is the 21-hydroxylase enzyme deficiency.
5 X8 K5 V# Q, O) @: H5 cThe 11-β hydroxylase deficiency may also result in- g6 Q7 W( ?: `
excessive adrenal androgen production, and rarely,, ] ^) v1 N U- n
an adrenal tumor may also cause adrenal androgen# D+ L9 X/ k; q- | T
excess.1,3
7 B, d. @0 c( c6 \# Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- x$ d5 S( b1 M& o0 C- v( [542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 {* G, t0 g; b( K$ ^5 M5 [A unique entity of male-limited gonadotropin-
2 y. O1 b s, n3 yindependent precocious puberty, which is also known2 f5 P/ u$ A) \
as testotoxicosis, may cause precocious puberty at a
. X: l s3 R, V1 G, `) |& J- Kvery young age. The physical findings in these boys
# |1 K8 e7 {& b1 Q! Wwith this disorder are full pubertal development,& t% W4 o8 V# Z
including bilateral testicular growth, similar to boys
5 j7 O# B2 p9 b' R4 n" Wwith CPP. The gonadotropin levels in this disorder3 E( O6 j/ }' T( F5 l& u
are suppressed to prepubertal levels and do not show5 K" ^+ z/ B2 \0 {
pubertal response of gonadotropin after gonadotropin-
8 }7 }" b' f3 r9 r8 l+ Creleasing hormone stimulation. This is a sex-linked
6 ]( K% H8 I* ?0 V5 Dautosomal dominant disorder that affects only
; S9 K8 m2 {. N* wmales; therefore, other male members of the family# k: K' R0 D' W7 O5 Y
may have similar precocious puberty.3' [& T; E9 R+ l- ~% g& @( z; U8 `
In our patient, physical examination was incon-
" {) N# T0 S" }9 D: @' Msistent with true precocious puberty since his testi-
- v t' _2 q; D& Z: lcles were prepubertal in size. However, testotoxicosis
9 ~6 J8 J; D. _was in the differential diagnosis because his father
; d4 v- [( t* P+ J* l5 e8 ]started puberty somewhat early, and occasionally,' |* O* d& Q: [; i7 w q j
testicular enlargement is not that evident in the
y: T3 A: V4 E+ S# zbeginning of this process.1 In the absence of a neg-
$ s+ N2 ?1 [0 o! j$ f" p3 oative initial history of androgen exposure, our* d9 F7 O! ^7 C3 O+ j
biggest concern was virilizing adrenal hyperplasia,! Y$ G8 n- E, n( j! w
either 21-hydroxylase deficiency or 11-β hydroxylase5 M/ ^! C2 I# P1 B& `9 o
deficiency. Those diagnoses were excluded by find-
$ X$ I7 B1 L' J! }ing the normal level of adrenal steroids.
- `5 v" r- i1 A9 W, |& v3 XThe diagnosis of exogenous androgens was strongly# ]) f6 M' }% l8 A- w
suspected in a follow-up visit after 4 months because: v1 x0 ?+ d, y7 h& k& y
the physical examination revealed the complete disap-+ l! J, C" A: `6 z0 S4 R
pearance of pubic hair, normal growth velocity, and
$ }$ w! Y7 T" J3 P/ b% [decreased erections. The father admitted using a testos-" K2 x6 F( h5 L7 A
terone gel, which he concealed at first visit. He was& G4 m! p! e! U) M; c; C) c" c
using it rather frequently, twice a day. The Physicians’
, q# ^ x% }4 t% l. e2 iDesk Reference, or package insert of this product, gel or$ W7 |% b; [1 Z% D3 q
cream, cautions about dermal testosterone transfer to
8 w8 O7 ~3 F$ p# L: @& f8 c" s1 N" V' wunprotected females through direct skin exposure.& l0 k0 u* E9 f7 w
Serum testosterone level was found to be 2 times the
, Q! r! K& N% i/ i) I# Y, ybaseline value in those females who were exposed to! `! t9 w7 b) t! |
even 15 minutes of direct skin contact with their male
0 i6 c* a+ Z C. b" Bpartners.6 However, when a shirt covered the applica-
- K( |& ^& {9 b9 L3 Qtion site, this testosterone transfer was prevented.
, J2 V, S' a9 t! ^Our patient’s testosterone level was 60 ng/mL,
5 l/ m- \, l( M1 y$ W0 Q; ]which was clearly high. Some studies suggest that1 M$ R. F6 \/ h( e) I
dermal conversion of testosterone to dihydrotestos-
$ X4 d% ^$ o. y+ U- h5 u% m9 Fterone, which is a more potent metabolite, is more
$ S% H/ Y' h+ b/ P0 }active in young children exposed to testosterone
' J: I) V& F+ f& v; K: Zexogenously7; however, we did not measure a dihy-+ C# K5 W4 a8 K0 I" i& v2 V* s {
drotestosterone level in our patient. In addition to1 I/ r3 S2 A9 b# W7 o
virilization, exposure to exogenous testosterone in
; }8 Y7 _% r3 Z$ ]/ r! M" k6 @children results in an increase in growth velocity and
) e& X. B( O' Z" m- ^) Hadvanced bone age, as seen in our patient.
) I7 q. w+ y. t+ Z, M8 iThe long-term effect of androgen exposure during
0 z; h$ `0 e3 f5 K4 kearly childhood on pubertal development and final. j; J4 f* O# v& ~! S( U" M
adult height are not fully known and always remain* Y8 E- H0 F3 t7 F% |
a concern. Children treated with short-term testos-
8 K% I% h# `9 ~ ]terone injection or topical androgen may exhibit some
9 g0 R$ t; {' v j; Y, Q, t4 m2 d" D! ?acceleration of the skeletal maturation; however, after2 U5 E ?1 B; J3 ~/ R* z
cessation of treatment, the rate of bone maturation- h2 L: x( L/ C; P1 e! k" z3 C
decelerates and gradually returns to normal.8,9* |) E7 Q0 f" X; j0 G
There are conflicting reports and controversy
# n2 A9 C9 A+ M8 B$ ]: T8 T+ {1 \, @over the effect of early androgen exposure on adult% F1 j2 M( ~0 y M
penile length.10,11 Some reports suggest subnormal8 A, F0 u) l- q' W- c, D
adult penile length, apparently because of downreg-
* l- D1 c5 p. Y) D& g! b: [ulation of androgen receptor number.10,12 However,# e) i# S4 x; t' Z$ ?
Sutherland et al13 did not find a correlation between
) `$ L1 o( k) V1 a) c+ uchildhood testosterone exposure and reduced adult
9 ~: Q1 R& a) w X& ^penile length in clinical studies.2 }6 z" L" R4 @3 f
Nonetheless, we do not believe our patient is7 i' f8 e5 O, `% | I/ Y
going to experience any of the untoward effects from) `2 }$ Q' h/ x0 K- f5 ?2 l
testosterone exposure as mentioned earlier because
! @: t* C/ }% a' Bthe exposure was not for a prolonged period of time.
& F5 f5 E; M0 [+ vAlthough the bone age was advanced at the time of
4 `* N1 [- ~8 h, Y+ o! y6 {diagnosis, the child had a normal growth velocity at+ u& ~. ?* A' E* l8 m
the follow-up visit. It is hoped that his final adult/ q, `! h, Q, z& S0 W# Y
height will not be affected.
3 I* m( j; I! w$ a0 u, F+ M- iAlthough rarely reported, the widespread avail-
' r+ U: M3 v, s9 d7 o2 {ability of androgen products in our society may" D4 i8 z; g$ ^3 T
indeed cause more virilization in male or female1 _2 j! T( V7 E9 a- r- h# j- m" ?9 x
children than one would realize. Exposure to andro- b" P6 f* v7 m3 l+ z! T; b- l
gen products must be considered and specific ques-, f( A) ?# R) I6 W6 T/ _2 f
tioning about the use of a testosterone product or
7 e0 L4 j) H6 b, }( S& j5 ^gel should be asked of the family members during
7 Y! l* B+ A1 s$ x5 fthe evaluation of any children who present with vir-
* G# d* y$ M) filization or peripheral precocious puberty. The diag-
6 S, A5 u" j9 t3 m# o; U @ u+ dnosis can be established by just a few tests and by
* v5 V* r% e6 Rappropriate history. The inability to obtain such a
`& I6 `$ n- H6 r Y* ?# b; ihistory, or failure to ask the specific questions, may {, b O0 x- O4 k, l
result in extensive, unnecessary, and expensive7 ~2 S3 l; L' Y4 K s) {9 l! O" v
investigation. The primary care physician should be( ]( m; {5 `9 Z4 W* F6 Q
aware of this fact, because most of these children
9 |8 A& c6 H. ^6 _- @9 Nmay initially present in their practice. The Physicians’" U, }* K' m# E5 Q$ p4 S$ w7 ?2 V
Desk Reference and package insert should also put a
& g5 \, D* H+ W ]0 Gwarning about the virilizing effect on a male or& h* E7 L7 |8 N
female child who might come in contact with some-( d, C' Q& m& S9 \; ^
one using any of these products.4 Q. ?: m d& h5 X
References
2 t& L+ I: P, t& S0 }/ V1. Styne DM. The testes: disorder of sexual differentiation
( A% S5 t% } c4 c1 f2 fand puberty in the male. In: Sperling MA, ed. Pediatric
/ Y2 C8 _0 E6 uEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 k6 U5 e6 h* }1 F* D) V2002: 565-628.1 c% [+ l8 T8 ~0 N t- z. ]! N5 E+ t; L
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) ]' v5 M7 i, S7 l% ?3 b/ `3 Y
puberty in children with tumours of the suprasellar pineal |
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