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Sexual Precocity in a 16-Month-Old$ p+ @9 f0 b! Y% J7 w
Boy Induced by Indirect Topical& b# K0 E0 S( X1 W( o5 L
Exposure to Testosterone' A* |% f3 a n- a1 R5 O/ N2 c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 E' S; D, x, i0 x. A
and Kenneth R. Rettig, MD1# t" @5 l4 X9 w. Q/ ?
Clinical Pediatrics
9 v! D6 o5 R: u! A5 y9 J: ?Volume 46 Number 6) X# s, w2 P& T, j7 v1 Y' ^6 L
July 2007 540-543
5 o- k, }- [$ k) J, X# {© 2007 Sage Publications7 o2 {0 \7 a- f" K- A
10.1177/0009922806296651
( F3 y! u; ~+ q5 d( shttp://clp.sagepub.com" N) E) ^3 _% b( c/ m. I# X1 V
hosted at
: l3 q2 _' k' g! ]http://online.sagepub.com. f, w4 ]* [& Q+ L3 r
Precocious puberty in boys, central or peripheral,
0 z. T- x# N& \is a significant concern for physicians. Central8 @7 V9 K3 I+ m' D
precocious puberty (CPP), which is mediated
0 ~2 \) D. m: z# c, e; ]" Ythrough the hypothalamic pituitary gonadal axis, has# q) z6 a0 h0 x* j+ K
a higher incidence of organic central nervous system
a0 f7 n* L* l3 r; s. hlesions in boys.1,2 Virilization in boys, as manifested
( M5 \& C* l" l7 Dby enlargement of the penis, development of pubic
0 m E9 l1 a6 M p. m2 uhair, and facial acne without enlargement of testi-- s2 a! {9 N% T( J
cles, suggests peripheral or pseudopuberty.1-3 We) h1 |$ Q2 Q& A/ ?
report a 16-month-old boy who presented with the( c1 `" }3 k8 C; U- k
enlargement of the phallus and pubic hair develop-
3 E1 w. C+ A' o6 u; s$ y' g. E* Nment without testicular enlargement, which was due+ R& Y6 O) _: U( Z" u
to the unintentional exposure to androgen gel used by
" S: N; e' Z' q6 r$ N3 Xthe father. The family initially concealed this infor-. e5 |" B% o0 a% X0 w6 ]
mation, resulting in an extensive work-up for this+ ]& ]0 t* w9 e$ p1 b
child. Given the widespread and easy availability of
0 X9 G- t; x* M$ @/ K0 `' Xtestosterone gel and cream, we believe this is proba-
+ p+ ~6 i: z2 Lbly more common than the rare case report in the* p8 N: X) y/ ^0 y3 l4 z
literature.4
5 y) t( ~/ C% ^. C% `Patient Report) f4 b/ [. k u, s8 O1 p0 a$ a
A 16-month-old white child was referred to the; f) f9 n, v! ] @/ {
endocrine clinic by his pediatrician with the concern
) T2 Y3 P6 \- z- gof early sexual development. His mother noticed
0 O$ l' w6 ^2 b- Olight colored pubic hair development when he was J: y: k2 t* k" C
From the 1Division of Pediatric Endocrinology, 2University of$ W0 e4 m; z8 |2 z6 ]* o
South Alabama Medical Center, Mobile, Alabama.# c$ ^$ ~5 s _$ h
Address correspondence to: Samar K. Bhowmick, MD, FACE,
+ D5 d. G! ]& P" n' M: TProfessor of Pediatrics, University of South Alabama, College of
* u8 C" A/ t' N* [Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 B( r' c( j9 Z8 o9 |" v
e-mail: [email protected].
0 Q4 ?4 e: Z% K/ b% Q/ vabout 6 to 7 months old, which progressively became; p; S4 J$ H/ L* t) B) `
darker. She was also concerned about the enlarge-. J7 S1 S8 X# T8 W2 }7 y
ment of his penis and frequent erections. The child. o9 X* Y& j7 a/ t1 n
was the product of a full-term normal delivery, with
! T4 X8 _2 @/ Ja birth weight of 7 lb 14 oz, and birth length of
2 m# n; x* R* D3 N6 X20 inches. He was breast-fed throughout the first year5 f! _4 `7 G5 A- k/ x# T
of life and was still receiving breast milk along with
. i. f6 Q# S, H; o+ u/ c: Asolid food. He had no hospitalizations or surgery,
( `9 j1 ^) Z ~5 ^: a+ k9 }* K A0 Sand his psychosocial and psychomotor development
; V, y7 W# v: C" ]" h& swas age appropriate.' `* f- A! e4 O6 o, G
The family history was remarkable for the father,
* D3 {- b" ~8 y1 vwho was diagnosed with hypothyroidism at age 16,
* @* n/ g3 L$ ~& j$ A' L# Gwhich was treated with thyroxine. The father’s3 L: b; o/ P9 {9 k
height was 6 feet, and he went through a somewhat4 y @: m! w J7 n ]$ I3 h0 g
early puberty and had stopped growing by age 14.
/ Z C( s, z7 a. I+ \2 }, xThe father denied taking any other medication. The& c3 C0 P8 y$ q3 V- w
child’s mother was in good health. Her menarche% R& n' \! A+ z
was at 11 years of age, and her height was at 5 feet, _: l0 V1 c) ~: x, q8 N$ t2 Q/ B
5 inches. There was no other family history of pre-3 U, P4 r+ m1 ?$ M* L2 B# C
cocious sexual development in the first-degree rela-5 I1 K3 w8 ?3 `" V, b4 n9 z: n
tives. There were no siblings.( Y N3 X9 N% f# R& H, V+ N
Physical Examination
/ h. ~8 K- `2 ^2 t0 D: h8 dThe physical examination revealed a very active,7 x. v% Z, {2 n/ e" a7 s6 ^
playful, and healthy boy. The vital signs documented
3 d" w& U7 x Oa blood pressure of 85/50 mm Hg, his length was! ^! A, \& _, l0 r( F
90 cm (>97th percentile), and his weight was 14.4 kg
! P+ J4 A! g% z( Y- W(also >97th percentile). The observed yearly growth
7 n2 p. [% b- B; J: L1 }velocity was 30 cm (12 inches). The examination of
: [% t, l$ T) h7 p5 {the neck revealed no thyroid enlargement.3 M1 X" w! g5 A! E* M+ x
The genitourinary examination was remarkable for
3 F) b( V; l: F1 menlargement of the penis, with a stretched length of
0 U$ l/ l5 r7 e% q7 O( s8 cm and a width of 2 cm. The glans penis was very well/ X- L) ?, I* `, z/ A; T5 i
developed. The pubic hair was Tanner II, mostly around) A% K6 l. e' b
5403 G4 ^: I- R4 e% d2 o; e; R
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the base of the phallus and was dark and curled. The
! T5 V; |# G7 g) M$ {4 ^testicular volume was prepubertal at 2 mL each." F: e. d% p/ F6 T: y8 y8 C" g
The skin was moist and smooth and somewhat9 S( a* l e' P! y( S
oily. No axillary hair was noted. There were no
& R* b7 l) w! C Sabnormal skin pigmentations or café-au-lait spots.6 U0 x/ X+ @) E
Neurologic evaluation showed deep tendon reflex 2+; m9 t$ `% H7 X [, e+ Q
bilateral and symmetrical. There was no suggestion, T$ r1 A$ v1 E3 h, K
of papilledema.* v: _4 c' g/ ~- O/ A" I
Laboratory Evaluation1 l( t) x# n& Y: D9 n* ~5 \
The bone age was consistent with 28 months by
2 {7 f% ?0 m7 O; Susing the standard of Greulich and Pyle at a chrono-5 t9 x2 j0 U" L( f! {; Y% R9 w% L! W
logic age of 16 months (advanced).5 Chromosomal
$ ^$ u: h2 M% V/ J/ H% R% P7 ]karyotype was 46XY. The thyroid function test- n1 ^" G9 @, `
showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 K+ e+ a7 ~2 w8 P0 ^! F, t5 ]
lating hormone level was 1.3 µIU/mL (both normal).4 V `; J, o7 J* ?3 `
The concentrations of serum electrolytes, blood
( @8 u1 q' G: Z% u! ?urea nitrogen, creatinine, and calcium all were: b. z' e0 m) j' k/ C
within normal range for his age. The concentration
- w* a$ @. Z+ Aof serum 17-hydroxyprogesterone was 16 ng/dL
' O; n5 [& G) ^* |1 B+ x(normal, 3 to 90 ng/dL), androstenedione was 20: [& |6 N# X) r' O$ P
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, t0 W6 R, `+ i9 |2 g
terone was 38 ng/dL (normal, 50 to 760 ng/dL), K* F8 K5 ]& [' [ C- O2 [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to6 f& I2 g7 a$ w6 M" ~
49ng/dL), 11-desoxycortisol (specific compound S)9 J% g2 F, U1 a/ N8 e& G! V5 F" a
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 _- `. N+ Z9 I
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; ^9 I* b# l' K8 f
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ N# i% r; w) P" V& r2 D
and β-human chorionic gonadotropin was less than
6 j7 t ]! \+ T& { c X5 mIU/mL (normal <5 mIU/mL). Serum follicular
" ~# b" D; r* X- P8 I( b/ tstimulating hormone and leuteinizing hormone$ c, c. m" K# S H& s) P, N$ r
concentrations were less than 0.05 mIU/mL7 r' A- w8 I/ r! H; j# l
(prepubertal).: e3 o& S& u. A
The parents were notified about the laboratory& O ^* e" e4 h1 ^
results and were informed that all of the tests were
5 ]8 R" u1 R7 Q$ z. k( i; enormal except the testosterone level was high. The
3 `6 h) W9 x. Efollow-up visit was arranged within a few weeks to$ }( o9 p1 E4 I" e4 D% I
obtain testicular and abdominal sonograms; how-
8 N* u) y' a1 ] ]8 ~, k1 rever, the family did not return for 4 months., [' a7 @% [$ d' D. s
Physical examination at this time revealed that the
$ z; w, _3 G* @( i: ~3 x& ]. `child had grown 2.5 cm in 4 months and had gained
/ g/ t$ Z( E$ C& O) q9 l! d2 kg of weight. Physical examination remained
' Z" j" c. @, }$ j$ A+ R Junchanged. Surprisingly, the pubic hair almost com-
2 J4 V# |; W+ ?$ Apletely disappeared except for a few vellous hairs at' v1 J" a8 w1 B
the base of the phallus. Testicular volume was still 2
7 w0 s( D* D; r% F' x) p9 F3 QmL, and the size of the penis remained unchanged.
. X' P: B) ?, [' ~7 QThe mother also said that the boy was no longer hav-" J" Z$ l2 D6 {6 x$ B0 V( {
ing frequent erections.+ q, M5 |* W$ N- n# X# B* K, W6 o
Both parents were again questioned about use of7 v0 t6 m: k G) {# G, |2 G
any ointment/creams that they may have applied to
3 T# u! t% v- E$ _/ Lthe child’s skin. This time the father admitted the' a( f2 @- @' @$ ?5 a0 W* X
Topical Testosterone Exposure / Bhowmick et al 541
( g9 p# s4 S& ~* E# t) L( B; L4 xuse of testosterone gel twice daily that he was apply-
3 x7 S$ ~# L/ wing over his own shoulders, chest, and back area for1 q; J& p2 r7 ^& T: `' J( H
a year. The father also revealed he was embarrassed
! p! o# z% e2 q; z9 E) D! ^. `to disclose that he was using a testosterone gel pre-& x, q) s& A; O h
scribed by his family physician for decreased libido( H: w. L' C) U; k1 E q6 Y% i5 c6 P
secondary to depression./ E+ U H' ?, w) V
The child slept in the same bed with parents.
! n' N* Y! ~4 O! ?. |The father would hug the baby and hold him on his. r+ Z4 j2 U0 i
chest for a considerable period of time, causing sig-6 B, q+ y; ?& s; I/ Q$ n C' a
nificant bare skin contact between baby and father.! c) f" |5 a+ A5 F& t
The father also admitted that after the phone call,, f" L3 S6 B0 y) m, w* ?
when he learned the testosterone level in the baby0 [& `* Q% g& ?' `5 ?; E/ \$ \! Y" R
was high, he then read the product information
0 P' h& c0 _4 O# i) y: hpacket and concluded that it was most likely the rea-
0 W+ g4 {/ x) ?" y( E ]son for the child’s virilization. At that time, they" I# X \) T7 B
decided to put the baby in a separate bed, and the
0 a% \, o1 }, `9 |/ a H& @& H- j+ tfather was not hugging him with bare skin and had3 v, S j6 K' j2 j
been using protective clothing. A repeat testosterone
# T4 X& N2 R' z$ @- r2 L& M- d! Rtest was ordered, but the family did not go to the
2 @ X, e4 \7 P1 jlaboratory to obtain the test.% Z, S- u s$ \
Discussion5 ~) M7 r+ }( D+ ?# K, k0 a5 [
Precocious puberty in boys is defined as secondary7 O- C1 F, r, O8 R5 @2 ?/ o
sexual development before 9 years of age.1,42 n G, w/ d5 w( L9 r% V
Precocious puberty is termed as central (true) when
. v* [* V/ q) t9 \0 \it is caused by the premature activation of hypo-& u5 F* W1 m" k
thalamic pituitary gonadal axis. CPP is more com-- Z& c. \3 }8 V$ N* s
mon in girls than in boys.1,3 Most boys with CPP
3 Y# V0 J/ h! zmay have a central nervous system lesion that is
) e( l0 P* g- T1 f9 _, Oresponsible for the early activation of the hypothal-
( h& m- p0 d c3 x$ X& Tamic pituitary gonadal axis.1-3 Thus, greater empha-
/ ]5 K8 `0 N; q8 msis has been given to neuroradiologic imaging in* |" W/ I7 r5 a( x# { ]
boys with precocious puberty. In addition to viril-
* V0 B2 J2 ^7 X+ w9 g1 J3 O" v. iization, the clinical hallmark of CPP is the symmet-
% m& v; Q* c6 j8 Urical testicular growth secondary to stimulation by
9 ^: m& U6 G# Igonadotropins.1,3. Y7 s. t) J) q- ~! r
Gonadotropin-independent peripheral preco-
1 U5 g2 V% U# Z7 k1 `7 I( @cious puberty in boys also results from inappropriate; e- @; |$ y4 B- n3 f' z) d
androgenic stimulation from either endogenous or
- e" D! q' h/ }5 O6 f* kexogenous sources, nonpituitary gonadotropin stim-
) w0 Y' d" x* {) p: mulation, and rare activating mutations.3 Virilizing
; G2 Y* l5 S4 s: B+ K ~congenital adrenal hyperplasia producing excessive" u& q# b3 ?: p K T1 z( S- i
adrenal androgens is a common cause of precocious
+ Q! O* d7 o3 N) h1 W- ?, gpuberty in boys.3,4
' ?0 J- D7 A2 K- T- OThe most common form of congenital adrenal. d# e+ p4 D' W' l6 G6 P
hyperplasia is the 21-hydroxylase enzyme deficiency., c% M5 A( p- E- U9 S
The 11-β hydroxylase deficiency may also result in
, j- G3 p8 h# @; H5 M1 L" ]& ^excessive adrenal androgen production, and rarely,
! g- h, Y Y3 ?6 C' van adrenal tumor may also cause adrenal androgen
3 p: M) ~6 o; G1 K6 r7 s1 Bexcess.1,3, S) }& A" Z8 [7 U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 h+ B. r/ p3 k542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 v& Y$ j3 M" y5 s, g* I1 ^
A unique entity of male-limited gonadotropin-
' A) \/ j; L0 m0 U$ u3 ]) Gindependent precocious puberty, which is also known
2 B; E7 S) p$ o$ h( V5 g% W' W! bas testotoxicosis, may cause precocious puberty at a
1 l$ q @' } O& | vvery young age. The physical findings in these boys
% l0 Y. g& c& h; jwith this disorder are full pubertal development,
) H. k# w' j0 Mincluding bilateral testicular growth, similar to boys
" `: y- x3 w. {$ t; bwith CPP. The gonadotropin levels in this disorder0 N- Y; v m# @* Q. y
are suppressed to prepubertal levels and do not show
8 X4 ]* L) K2 M. Upubertal response of gonadotropin after gonadotropin-! R/ I+ h5 r7 B9 o5 E0 |
releasing hormone stimulation. This is a sex-linked9 {0 g7 f* `5 l; |8 s- {& i0 Q
autosomal dominant disorder that affects only
# z! R) h( H: I# U+ g: l: T1 p' Smales; therefore, other male members of the family1 L. l/ L! E7 R0 x: Q
may have similar precocious puberty.3
& M7 N$ P2 }$ E, I m* FIn our patient, physical examination was incon-0 r; K, @; T5 U' c
sistent with true precocious puberty since his testi-# k* J+ D; }( T! ^. v0 O, {$ A
cles were prepubertal in size. However, testotoxicosis, c* s7 ] R8 t9 M
was in the differential diagnosis because his father+ p, G/ G( n3 F0 }
started puberty somewhat early, and occasionally,4 h5 \9 f* B* m
testicular enlargement is not that evident in the3 a: S9 l( y8 C4 I
beginning of this process.1 In the absence of a neg-
' v- I% Z( O1 x. dative initial history of androgen exposure, our
3 o+ R8 P0 C+ G7 N' m9 J, ], Hbiggest concern was virilizing adrenal hyperplasia,7 O- x7 z' n5 z b& p6 O# Y- ~/ ~" N
either 21-hydroxylase deficiency or 11-β hydroxylase
: F/ v' N7 W, a2 sdeficiency. Those diagnoses were excluded by find-
! \4 v( O9 _* P- ?ing the normal level of adrenal steroids.6 {, X$ s, [, M+ x) ?' d' C% d
The diagnosis of exogenous androgens was strongly: k; t x. x3 ], k" y X
suspected in a follow-up visit after 4 months because, f) Q: {. d) ~5 I
the physical examination revealed the complete disap-
7 R( J5 T D: Y; Z* p5 F5 ipearance of pubic hair, normal growth velocity, and
) A! n2 j% m9 V0 S+ ~' Xdecreased erections. The father admitted using a testos-; H$ X( C5 v& Z' W/ V
terone gel, which he concealed at first visit. He was: b* ?; Q2 d' a$ [( |& k' t
using it rather frequently, twice a day. The Physicians’
1 W) ?, y H5 v! l f8 R0 ^Desk Reference, or package insert of this product, gel or9 Y, c6 L6 b4 J/ Z7 ]* F
cream, cautions about dermal testosterone transfer to* X* [. ?/ W( }! r2 B
unprotected females through direct skin exposure.
! C; _8 Q0 t# L$ N& Z3 gSerum testosterone level was found to be 2 times the B$ B' F- @, |. C
baseline value in those females who were exposed to5 K9 u# |- {) x4 i- f
even 15 minutes of direct skin contact with their male/ `* `7 B, k4 W7 K; o4 E
partners.6 However, when a shirt covered the applica-6 x# k6 R5 w8 {) c5 u. [
tion site, this testosterone transfer was prevented.
* d6 L, u) n3 aOur patient’s testosterone level was 60 ng/mL,
& `$ B) ~2 r4 [+ g8 ?which was clearly high. Some studies suggest that
" x, L7 [8 O: u0 T7 @; ]dermal conversion of testosterone to dihydrotestos-/ Q* I) n6 |/ v' j e
terone, which is a more potent metabolite, is more
! R1 j8 y o* [& R% vactive in young children exposed to testosterone
/ C$ T) y* c/ Bexogenously7; however, we did not measure a dihy-4 a. `0 L+ d. Z( h( n, R
drotestosterone level in our patient. In addition to
. e& }2 O: w& x+ z9 T/ Avirilization, exposure to exogenous testosterone in
& Y7 X1 t& a" y. Zchildren results in an increase in growth velocity and
' A$ r2 M! W" e$ Fadvanced bone age, as seen in our patient.
: E# [, _' M% Y$ V& NThe long-term effect of androgen exposure during
9 l! D6 W) _7 f( wearly childhood on pubertal development and final6 w, O8 M+ [: ]' C
adult height are not fully known and always remain
, m8 p; s, w) C$ [; g* qa concern. Children treated with short-term testos-: T+ o; r" r1 P' R7 a4 e# c
terone injection or topical androgen may exhibit some
6 P ~- E1 y; p7 Hacceleration of the skeletal maturation; however, after: I o2 |# w. k" X
cessation of treatment, the rate of bone maturation
* @4 M( ]* H' ^! W8 ndecelerates and gradually returns to normal.8,9. S7 z# O6 i( Q6 z( P: y
There are conflicting reports and controversy
4 D4 k$ A) U) |) w7 A. F! y$ eover the effect of early androgen exposure on adult% S7 D4 l8 U7 m. ?7 b: i; ?/ Z- D
penile length.10,11 Some reports suggest subnormal
- _: u h! |1 Yadult penile length, apparently because of downreg-: _$ D4 `, s! U- T) p$ C
ulation of androgen receptor number.10,12 However,
: b* ?# P8 ?, M/ E' KSutherland et al13 did not find a correlation between6 R: f+ v# B ]
childhood testosterone exposure and reduced adult
* M) B4 @2 _5 L" `3 L3 ]% ~# [3 Tpenile length in clinical studies.) Q) u9 N- _8 S5 H' n, t2 R
Nonetheless, we do not believe our patient is
: [" j! G+ I! D+ P; R( S3 q6 Jgoing to experience any of the untoward effects from
- |: B2 t D; ?/ [3 Gtestosterone exposure as mentioned earlier because
& S% h( S A) D4 `the exposure was not for a prolonged period of time.
* ]+ [" B9 W4 W+ T+ k0 ?; YAlthough the bone age was advanced at the time of
" L# c5 ]! |1 ~8 Z5 K7 ^: K# E: fdiagnosis, the child had a normal growth velocity at
. W% y, V J& D+ ethe follow-up visit. It is hoped that his final adult9 O4 i' w2 P2 k: X; h5 q
height will not be affected.6 o* ]: t1 M7 ?3 U9 u4 E& m; `
Although rarely reported, the widespread avail-
& T2 n% A G8 \3 Oability of androgen products in our society may1 Y( p) Y0 d/ ?3 E% \
indeed cause more virilization in male or female
: {0 N' L2 X, |) V) M# wchildren than one would realize. Exposure to andro-
5 V. i2 x+ N2 k3 c% Vgen products must be considered and specific ques-
9 Q( F: J$ a% [/ L0 ptioning about the use of a testosterone product or. z; r# t3 y1 q& I# l
gel should be asked of the family members during! Y* Y5 L N* U m) r( s
the evaluation of any children who present with vir-; Q) C$ k) ~% I- j; W! w! K
ilization or peripheral precocious puberty. The diag-. Q9 `, K/ I' k8 p- _
nosis can be established by just a few tests and by
: D3 f; u) @ ~+ ?" O/ Y# gappropriate history. The inability to obtain such a
~0 b* Z% d- {( {# q, X3 B% [history, or failure to ask the specific questions, may: B8 ^- k% o" P- X! l/ F
result in extensive, unnecessary, and expensive
+ x8 S; ~, X4 l1 d7 U l* [# Rinvestigation. The primary care physician should be% l$ y0 b& r( c9 {0 I
aware of this fact, because most of these children
; h" D& A: n( p! U. D6 Lmay initially present in their practice. The Physicians’3 N; ~9 R- v X! }- p
Desk Reference and package insert should also put a
* h4 u; Q3 L! h9 gwarning about the virilizing effect on a male or
$ Q! L6 b; F* B: U- efemale child who might come in contact with some-( M* O Z/ X9 B- x% m
one using any of these products.
8 f1 _* N7 H. z& ~: ]2 jReferences
; z8 u' E, p7 C' G. _1. Styne DM. The testes: disorder of sexual differentiation
1 L2 c6 m+ b. T+ Vand puberty in the male. In: Sperling MA, ed. Pediatric
" y) ~9 t& K1 z# H' k4 A! WEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
n1 {% H( S: L8 S7 L# v, K2 U) H6 G2002: 565-628.
9 k% L, M; G+ r0 [+ b/ v7 W0 _2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ _3 C0 I' T( |. B
puberty in children with tumours of the suprasellar pineal |
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