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Sexual Precocity in a 16-Month-Old4 ^( v5 ^: D3 r4 v1 C, }! r) F
Boy Induced by Indirect Topical$ ^3 V, X7 P" z
Exposure to Testosterone
8 }. G, `' K3 u4 w: }Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- `1 A9 A0 Y3 t& }0 r3 H
and Kenneth R. Rettig, MD1! ?! _- y( D, A! \) T- G* {
Clinical Pediatrics
' [- J& H3 o) b: C9 uVolume 46 Number 69 [9 i4 f1 N' ]' ^) M
July 2007 540-543
" S; p) U' \% Q: y© 2007 Sage Publications
) `' ?; A, ?2 y+ m7 q10.1177/0009922806296651
6 i8 z3 ? h, H! O4 dhttp://clp.sagepub.com0 ^7 I" W1 q' v; r" _. ?
hosted at+ _! A% u" _' b1 _7 x
http://online.sagepub.com$ ]$ y1 q( E2 {( t% m) _* Y! E
Precocious puberty in boys, central or peripheral, ^4 K/ k- R* ^. B
is a significant concern for physicians. Central T7 O$ h9 a ~$ t3 W
precocious puberty (CPP), which is mediated
$ i9 p* [: Y* A3 x8 f, [7 Wthrough the hypothalamic pituitary gonadal axis, has* L! i) P! z' D4 g i3 C
a higher incidence of organic central nervous system0 [. W Q, r! \6 @' \
lesions in boys.1,2 Virilization in boys, as manifested
9 r' }; _/ `; _: F# J; D) Zby enlargement of the penis, development of pubic1 Z, l! r6 Q* u! X9 t/ {
hair, and facial acne without enlargement of testi-
1 V1 U1 C3 H) e/ i- scles, suggests peripheral or pseudopuberty.1-3 We" }4 ^ o: l w; y& X, V
report a 16-month-old boy who presented with the0 F2 v6 f) ^% @. l8 u9 `
enlargement of the phallus and pubic hair develop-
' Y9 F& Y. b4 l4 ement without testicular enlargement, which was due
4 ?8 I8 [( E( U2 xto the unintentional exposure to androgen gel used by7 Z; b, u5 W+ |, W- b* B z
the father. The family initially concealed this infor-3 b, o8 y3 V, u; ~' I/ \: v
mation, resulting in an extensive work-up for this
* S: f% X- h' \5 x1 ichild. Given the widespread and easy availability of4 v+ p1 P' ]: f" D
testosterone gel and cream, we believe this is proba-! ^1 J2 m1 q1 | J! b* }
bly more common than the rare case report in the4 S( \9 O, E) i5 E
literature.47 j. J- I" C" y* i I' D
Patient Report% o: p3 |- N9 M# g5 b) t
A 16-month-old white child was referred to the
: b' w. U* W( [- E5 Y% I5 @/ ~endocrine clinic by his pediatrician with the concern- `4 R B5 U; ]
of early sexual development. His mother noticed
6 c& s1 z& s5 d, `& o) zlight colored pubic hair development when he was4 h+ K, s% f! @9 m+ l" f
From the 1Division of Pediatric Endocrinology, 2University of
0 x; G; Z4 ]4 Y2 PSouth Alabama Medical Center, Mobile, Alabama.; D! U8 _$ n3 B& ~
Address correspondence to: Samar K. Bhowmick, MD, FACE,
0 L: |3 j) ]# I# h9 G5 o' QProfessor of Pediatrics, University of South Alabama, College of4 C1 E; x2 V6 S% S3 D( k/ r
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( E) C8 h+ R- p/ e
e-mail: [email protected].4 `8 m' |) S7 L$ f- N5 i
about 6 to 7 months old, which progressively became
/ l+ {1 [4 R+ v2 ?- U4 Z* mdarker. She was also concerned about the enlarge-; g! W) v, M/ X- k- O' r
ment of his penis and frequent erections. The child9 l! }& z4 i9 B( {! l7 c
was the product of a full-term normal delivery, with
- S9 s; A7 t, V9 Za birth weight of 7 lb 14 oz, and birth length of
$ J/ W w# `; i5 s+ T. N( R20 inches. He was breast-fed throughout the first year9 Y. ?- @7 c3 |& Z' w
of life and was still receiving breast milk along with
7 w7 |& w: k' V; o6 \ Dsolid food. He had no hospitalizations or surgery,
7 b$ s2 q) @" |and his psychosocial and psychomotor development5 _/ c7 r# F1 m7 H/ b
was age appropriate.
Q; X- t* W* N) PThe family history was remarkable for the father,
6 J9 N6 W3 u( ^9 O8 Ewho was diagnosed with hypothyroidism at age 16,$ ?2 O! r- ?8 c0 ~
which was treated with thyroxine. The father’s, i. i s& g5 d
height was 6 feet, and he went through a somewhat* [9 m# e- t* j' d7 H
early puberty and had stopped growing by age 14.
$ ^" C' h9 Z9 pThe father denied taking any other medication. The! l& |" I' H. R$ g! {5 Y* t2 H% u
child’s mother was in good health. Her menarche
( u) }! a% O! G; H2 W- N" ~* ywas at 11 years of age, and her height was at 5 feet
! c& b" T; o8 k5 inches. There was no other family history of pre-4 k% `5 [0 y0 `$ b6 P& d1 _$ J `# n$ |8 M* X
cocious sexual development in the first-degree rela-
4 d1 G0 `, _7 U4 M6 [2 G/ Ktives. There were no siblings." c6 Z" T& F- L- A/ L# ^# Y
Physical Examination+ e; V# l4 d' i( h' M; `
The physical examination revealed a very active,7 @1 s* a( B0 f0 `' P
playful, and healthy boy. The vital signs documented
+ `6 A* N j% @' K1 l: W8 }a blood pressure of 85/50 mm Hg, his length was
$ M) I, L& S0 m, g90 cm (>97th percentile), and his weight was 14.4 kg
6 d) k7 g U( X, W) b$ m(also >97th percentile). The observed yearly growth
' N8 F' e2 E& Avelocity was 30 cm (12 inches). The examination of' ~9 W# K6 I; m! G" Y5 `
the neck revealed no thyroid enlargement.
& C/ N) N" A. ?" _- u: ]2 xThe genitourinary examination was remarkable for
- X: O' z, l2 i u, tenlargement of the penis, with a stretched length of t+ n3 M) f n4 B7 M2 ?: J& g8 I
8 cm and a width of 2 cm. The glans penis was very well2 U3 n+ _/ F" i( r2 f
developed. The pubic hair was Tanner II, mostly around4 S# R: n& K& ^6 H; I9 Z
540& }' J! k8 F7 ~/ j! m) h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 ]3 j5 h2 }+ K/ O& J$ ?" Sthe base of the phallus and was dark and curled. The! j' v' @: y6 A% k4 z
testicular volume was prepubertal at 2 mL each.
3 U. r+ Q' @' |. UThe skin was moist and smooth and somewhat
: ?) j5 s1 N5 s9 c) koily. No axillary hair was noted. There were no
1 [6 I2 o! Z# gabnormal skin pigmentations or café-au-lait spots.
( M* C) l& U* ^" O+ mNeurologic evaluation showed deep tendon reflex 2+
& i' p- [: D. s" Y! k# a. wbilateral and symmetrical. There was no suggestion, d# Z8 _5 W/ x8 r
of papilledema.
1 |6 F5 `, }3 m( t6 C4 J& tLaboratory Evaluation
+ z j* V: I; QThe bone age was consistent with 28 months by
4 y$ @- W. m7 S! A; y6 @, e+ nusing the standard of Greulich and Pyle at a chrono-
; O$ x$ K2 q S9 U, ^logic age of 16 months (advanced).5 Chromosomal
" O6 ]9 ^& g( n- jkaryotype was 46XY. The thyroid function test
# b8 o( A6 o9 ?showed a free T4 of 1.69 ng/dL, and thyroid stimu-
; X, B( ^0 |7 R5 Alating hormone level was 1.3 µIU/mL (both normal).
b- a' }4 G, zThe concentrations of serum electrolytes, blood
5 _, Z C8 `$ ^urea nitrogen, creatinine, and calcium all were
% g' M1 Y& n8 @' a1 z2 v4 `' a' v( ?within normal range for his age. The concentration: E& c' G9 }: L, g0 a' `; j
of serum 17-hydroxyprogesterone was 16 ng/dL2 i8 E0 a. t( z- Q8 R8 m
(normal, 3 to 90 ng/dL), androstenedione was 20
, V7 k% g0 ^7 {1 C+ Z/ kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ L8 |# p. M7 k8 tterone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ y' ]+ E& u. I6 _' Q% L" @0 I; ~9 ^desoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ y% p- ?# n3 a49ng/dL), 11-desoxycortisol (specific compound S)
( H9 v6 K4 L/ W7 a$ I2 Awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- s* }2 K1 K8 ?. G
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 X5 k. ~: Z; N9 ftestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# R* g5 A) x, o" O! c8 a( Eand β-human chorionic gonadotropin was less than6 a5 A: Y: `* I+ j7 I
5 mIU/mL (normal <5 mIU/mL). Serum follicular3 ` ?/ B/ J0 |3 C, ?
stimulating hormone and leuteinizing hormone* ?# l# l+ c) S. o
concentrations were less than 0.05 mIU/mL
+ {) M1 k/ o" e7 [9 G(prepubertal).
) k/ |9 {* {. z# eThe parents were notified about the laboratory% e- v& `# u, G2 Z( k I
results and were informed that all of the tests were
& z0 ]% M" j% A) L$ ?8 @; fnormal except the testosterone level was high. The
- `3 D5 k! N! m) F0 Ufollow-up visit was arranged within a few weeks to- W1 T8 b7 Q) m' q( e# w/ u' C. o
obtain testicular and abdominal sonograms; how-
8 Z- H4 }' J3 E8 Vever, the family did not return for 4 months.2 z) k, h, c2 h1 Z
Physical examination at this time revealed that the) i% k! ]% t5 G* {3 _/ z
child had grown 2.5 cm in 4 months and had gained
# a- T+ C* I- Y$ i& ^2 kg of weight. Physical examination remained
: F4 O: L+ g2 _. b8 x+ ^( H0 junchanged. Surprisingly, the pubic hair almost com-; f5 D$ l6 N5 a/ C/ `
pletely disappeared except for a few vellous hairs at
2 ? o ^! h1 e, b* ~ M; b# J Vthe base of the phallus. Testicular volume was still 2! o+ J$ ]+ s" T9 _) W# r' L) W
mL, and the size of the penis remained unchanged.
, }. K5 E, I' m D2 YThe mother also said that the boy was no longer hav-- }1 y. |- ^: L, r3 g+ l& z8 ?
ing frequent erections.+ G+ w3 k) i7 f* k q" z
Both parents were again questioned about use of
' l% e6 P$ u8 u6 w% |any ointment/creams that they may have applied to
. o" f6 N/ H+ G, J/ [$ A) m) a* uthe child’s skin. This time the father admitted the
7 s$ f! Y' D& s" L1 F y- ETopical Testosterone Exposure / Bhowmick et al 541* l' L5 `! i z+ x* h8 U: y
use of testosterone gel twice daily that he was apply-
- \0 s/ Q9 J: O9 x: c2 {9 \- fing over his own shoulders, chest, and back area for) n* p' y0 o; L4 k7 s) {7 L
a year. The father also revealed he was embarrassed
; E" [, u& |4 Q' A$ B0 e" Sto disclose that he was using a testosterone gel pre-! p0 {6 F8 D/ g
scribed by his family physician for decreased libido9 ^8 w- h, N% N* a3 h, ~
secondary to depression.
" `4 M" L0 d2 `( OThe child slept in the same bed with parents.
8 I# p( \4 L' A! l3 _6 h2 I' SThe father would hug the baby and hold him on his
% n; q6 K/ Y/ m0 V" Kchest for a considerable period of time, causing sig-
8 l8 j U# j- }( ?# vnificant bare skin contact between baby and father.
; l: L1 a! P1 OThe father also admitted that after the phone call,
+ o7 N! E# d* d* a5 U2 Gwhen he learned the testosterone level in the baby
5 m8 C" e6 Q8 r4 ~0 J8 Wwas high, he then read the product information: B; ]3 E$ i+ ~% j3 b$ \
packet and concluded that it was most likely the rea-
1 c, m9 j3 l# _+ oson for the child’s virilization. At that time, they, [0 H+ m% q4 Q" W9 Y
decided to put the baby in a separate bed, and the
8 p% p Q. b3 ?1 m$ efather was not hugging him with bare skin and had
* Y2 N7 p; J- ~9 u" H4 _- e. \' Abeen using protective clothing. A repeat testosterone
+ D; b' {8 J( L ]3 Ttest was ordered, but the family did not go to the
9 {9 T9 b" c3 Z& w Jlaboratory to obtain the test.
0 U+ \( U7 P( q0 ^" V" yDiscussion& X7 ^: B# m2 |4 ]2 i8 P. l" d
Precocious puberty in boys is defined as secondary' O6 Y2 o. L9 U1 y& r$ ^3 j
sexual development before 9 years of age.1,46 X) R! {& R7 |! M& D6 g" a
Precocious puberty is termed as central (true) when" }4 D9 S2 P# d) M% N
it is caused by the premature activation of hypo-
" a. r3 ^7 p% I5 r) z$ k; ~% mthalamic pituitary gonadal axis. CPP is more com-
; k7 c7 ^: C2 @( N, bmon in girls than in boys.1,3 Most boys with CPP ?4 o4 B$ E( U
may have a central nervous system lesion that is
$ ~( i- J' D( {) h% T! \; H qresponsible for the early activation of the hypothal-, \: [* p6 b# ~" b' d
amic pituitary gonadal axis.1-3 Thus, greater empha-
6 T: O6 x: I+ ? Hsis has been given to neuroradiologic imaging in
) y3 Y3 U+ A0 ^0 K& eboys with precocious puberty. In addition to viril-3 z, Q3 v- K9 Y/ g s g1 R5 T% c0 C
ization, the clinical hallmark of CPP is the symmet-
. A5 b1 ^/ @- ]5 x0 A5 V1 E. L7 \2 Wrical testicular growth secondary to stimulation by
+ f% ?9 C% G, r# a- Ggonadotropins.1,3
8 \/ X5 K6 V5 [- M: C" B/ }Gonadotropin-independent peripheral preco-
& I8 l: a% j* d, h \1 ^cious puberty in boys also results from inappropriate0 V- f, v4 v& p6 e# y T
androgenic stimulation from either endogenous or" E! f: @# m, h2 j7 ~1 ^
exogenous sources, nonpituitary gonadotropin stim-
% Y( P ?/ ~' a x- Wulation, and rare activating mutations.3 Virilizing
9 p# T+ p% R8 `$ Ncongenital adrenal hyperplasia producing excessive
1 p2 R/ y+ }, o# | ~0 J t! P" [adrenal androgens is a common cause of precocious
3 G0 _2 |, I' a" Opuberty in boys.3,4
4 ~2 F# ~3 Q) a: TThe most common form of congenital adrenal
! w4 R+ V3 d, u& j. b9 Uhyperplasia is the 21-hydroxylase enzyme deficiency.( G- x/ V6 v1 F5 [1 A( ]2 G H! V
The 11-β hydroxylase deficiency may also result in
! n2 M9 g- O% l$ R4 y1 gexcessive adrenal androgen production, and rarely,
; D% J! h5 i$ n5 t2 t- \, Han adrenal tumor may also cause adrenal androgen
4 b3 e" q+ l6 W0 \excess.1,37 y8 Z) ~( S. }( n
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
|- m, [ s7 i" {3 H" z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ _, O7 n, F" e- ?+ ]0 c+ GA unique entity of male-limited gonadotropin-8 X3 t) E' T7 Q& G$ S3 o0 s
independent precocious puberty, which is also known
3 ^. X% J+ d7 [+ X. f; g/ Yas testotoxicosis, may cause precocious puberty at a% X5 d4 w0 W/ D/ k8 G9 h
very young age. The physical findings in these boys
1 n+ v2 B* A0 l) e$ E/ H9 Hwith this disorder are full pubertal development,+ S2 x: c b+ x7 c
including bilateral testicular growth, similar to boys
1 V& H& m4 J; }' Iwith CPP. The gonadotropin levels in this disorder
) Z2 W5 M I5 l4 Q, r9 l. _' D3 ]( |7 q- Gare suppressed to prepubertal levels and do not show9 P6 x/ S. W7 B K- x$ u* n
pubertal response of gonadotropin after gonadotropin-- d% E1 _* o* N
releasing hormone stimulation. This is a sex-linked/ N2 V) H, j( O
autosomal dominant disorder that affects only! _7 F* H+ e4 p
males; therefore, other male members of the family9 I8 ?0 A* \# F: t% }: e% H
may have similar precocious puberty.3
3 w' H7 b" P: k* ]% `/ aIn our patient, physical examination was incon-
! l! _) @3 Z& ~! f3 h' dsistent with true precocious puberty since his testi-/ `5 ~4 E$ q3 ^! e
cles were prepubertal in size. However, testotoxicosis) L* J9 H3 t; a+ d* F, T
was in the differential diagnosis because his father* U! q; G+ B" K3 m( V
started puberty somewhat early, and occasionally,# }1 X, A+ z3 ~; u7 S/ d
testicular enlargement is not that evident in the
: X. X: E- ~+ W& h1 O# Zbeginning of this process.1 In the absence of a neg-
( w! D3 R4 \; h0 K( ]9 h. Z! zative initial history of androgen exposure, our( |( ~% e7 q% M/ E: @
biggest concern was virilizing adrenal hyperplasia,, t" p) v/ p+ C1 j2 H: G
either 21-hydroxylase deficiency or 11-β hydroxylase
* V+ I3 o' K V6 p) kdeficiency. Those diagnoses were excluded by find-9 r/ I% }& B" h# N. K z4 T2 g$ i( p
ing the normal level of adrenal steroids.* N- s$ W* |8 J1 Q, m
The diagnosis of exogenous androgens was strongly
% z4 I. Y6 s+ W+ h3 }3 D) Ususpected in a follow-up visit after 4 months because
. e. z- M& q) O7 F5 G, ~7 V0 uthe physical examination revealed the complete disap-1 _3 r/ @% z! V: j6 R' H
pearance of pubic hair, normal growth velocity, and
5 i( L! X Q# F4 V; a# }decreased erections. The father admitted using a testos-; h( z* _$ ?. S5 B
terone gel, which he concealed at first visit. He was3 Z4 ]3 ]. l6 H. ~( o! C
using it rather frequently, twice a day. The Physicians’- G1 u! r0 ~7 H; r
Desk Reference, or package insert of this product, gel or" `# @ Z: e$ g& X( P, M2 A
cream, cautions about dermal testosterone transfer to
: L. |2 M. X( l, D9 x" x: w& runprotected females through direct skin exposure.9 m+ T3 P% B( g- i5 |
Serum testosterone level was found to be 2 times the
5 `/ j/ b2 n% U+ V2 c( z) hbaseline value in those females who were exposed to9 n, }5 t3 c7 t: f8 d. c
even 15 minutes of direct skin contact with their male
0 i1 T& u( b% e8 p7 vpartners.6 However, when a shirt covered the applica-5 ^7 f7 I: {9 S' o7 K: X0 k
tion site, this testosterone transfer was prevented.& H, U, @4 J; q+ r/ K2 E8 G
Our patient’s testosterone level was 60 ng/mL,
1 |# i4 O& _5 b: K( @" L8 \which was clearly high. Some studies suggest that6 b4 X# W0 e& Z- H$ m4 A# v
dermal conversion of testosterone to dihydrotestos-
( o- P. I) N p! A4 Hterone, which is a more potent metabolite, is more8 \ Y# J& p2 \# l4 {
active in young children exposed to testosterone
3 C' m$ ]4 D6 y! J0 wexogenously7; however, we did not measure a dihy-
. m" Y* |$ B1 Q, }drotestosterone level in our patient. In addition to' o u( T! v j+ V8 S7 J7 j
virilization, exposure to exogenous testosterone in
. l+ V* Q/ g7 N3 j8 ?0 Achildren results in an increase in growth velocity and
3 {$ \# u! K% q+ J. u7 }advanced bone age, as seen in our patient.
5 ?* c/ |' \: M& G$ TThe long-term effect of androgen exposure during
. w- j5 f7 B( D% pearly childhood on pubertal development and final
9 _0 s! y( C; c& ]( T0 u5 vadult height are not fully known and always remain' f. P. m1 N5 M7 C7 ]6 y q
a concern. Children treated with short-term testos-: u5 N& C* x2 W) K$ w" Z2 _
terone injection or topical androgen may exhibit some
1 S$ a o5 H6 g1 p- C/ f6 Uacceleration of the skeletal maturation; however, after
' x+ `# b7 Q+ i8 ?# @/ `9 j3 tcessation of treatment, the rate of bone maturation2 ^3 b+ C" b6 K" P* L" [
decelerates and gradually returns to normal.8,9
+ X( y$ ?0 T4 l) ?- ~9 M! d0 q/ pThere are conflicting reports and controversy* \' e3 G6 O. `0 B& `0 b' `
over the effect of early androgen exposure on adult
' l( }2 y e6 n* [3 p" a* q. K ^penile length.10,11 Some reports suggest subnormal9 N- C& ~: i. _$ }! q
adult penile length, apparently because of downreg-8 P s9 F8 K% ^5 ~+ d
ulation of androgen receptor number.10,12 However,2 O! C9 f5 P! N
Sutherland et al13 did not find a correlation between7 x+ J+ a: k) Y" v! W' o
childhood testosterone exposure and reduced adult
4 S k+ `& b2 Q# A% `; C! mpenile length in clinical studies.- t6 u" |! z, v z, c# R$ `& ~
Nonetheless, we do not believe our patient is. H# `8 o$ n& A4 e+ v
going to experience any of the untoward effects from# t9 }) }3 O; u. U4 ]
testosterone exposure as mentioned earlier because/ J6 c5 v$ ?, i M9 j: V9 k' K
the exposure was not for a prolonged period of time.
& z- |0 z# ]6 C8 \! v) cAlthough the bone age was advanced at the time of4 \' Q8 g' e+ F8 ^# V; R* \
diagnosis, the child had a normal growth velocity at
1 b: T" b" s/ t9 J* W4 bthe follow-up visit. It is hoped that his final adult
5 R& t, M+ s. Cheight will not be affected.) [0 [; X7 C# `/ ]1 b$ j
Although rarely reported, the widespread avail-
8 D: `+ t2 l! C2 L2 m6 ~0 F$ hability of androgen products in our society may
3 [, m% k. v) o4 t5 Bindeed cause more virilization in male or female
. Z8 r" Z! R: [& F/ t2 K# n6 J+ Wchildren than one would realize. Exposure to andro-
; {4 e% S; @1 q! J. Z1 Bgen products must be considered and specific ques-
' R$ U& i' d |) D: N" utioning about the use of a testosterone product or
8 L- G- F1 l* igel should be asked of the family members during+ o/ L2 C1 R; I) T
the evaluation of any children who present with vir-
3 v k7 `/ d# t7 oilization or peripheral precocious puberty. The diag-
! y [ K0 H* t' j7 q- v/ H! Hnosis can be established by just a few tests and by& s: T- b, a* N/ i) Q
appropriate history. The inability to obtain such a
- ]+ ^7 R0 _* C- `4 N3 r ~0 bhistory, or failure to ask the specific questions, may6 L6 F) {1 g7 Z1 x2 R+ N
result in extensive, unnecessary, and expensive* |7 H9 r+ a! F3 T/ T2 e$ ^
investigation. The primary care physician should be
) ^: s4 U7 r' haware of this fact, because most of these children8 h y4 P- O% ~4 m* Y: f
may initially present in their practice. The Physicians’. g: K- q# I' c' _! k" ^
Desk Reference and package insert should also put a
5 o N- M a0 _/ Rwarning about the virilizing effect on a male or
7 b" w+ |( q2 Lfemale child who might come in contact with some-
# Y) {$ d2 L% xone using any of these products.' |) h( d1 r- R9 u" B4 T& F/ r
References
( _' I4 s3 E0 R1. Styne DM. The testes: disorder of sexual differentiation8 _: j) z' D5 X4 ]" f+ D- c1 a
and puberty in the male. In: Sperling MA, ed. Pediatric; `* x. x2 Y$ M* q/ V
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# |4 n8 Q( E- `9 {9 k0 {% [2002: 565-628.
" n9 U, V6 N5 F: u+ n; `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
; [- ~1 Z: d% H( [% l3 bpuberty in children with tumours of the suprasellar pineal |
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