A Case of Peripheral Precocious Puberty May Be Caused by a Diet Containing Phytosterols in a 20-Month-Old Boy

INTRODUCTION

Precocious puberty in boys generally remains an etiology. In addition to the causes of endogenous hormone changes, endocrine-disrupting chemicals of exogenous substances may interfere with children's pubertal development.

CASE PRESENTATION

A 20-month-old boy presented with peripheral precocious puberty may be due to a phytosterol-containing diet. The patient came to see a doctor because of acne, hairiness, increased penis size, and coarse voice. Genital examination revealed a Tanner stage of 2 for pubic hair and a stretched penile length of 5 cm, which disagreed with the prepubertal testicular volume (2 mL bilaterally). At the same time, he was found to have pigmentation on both nipples and areola. The concentrations of estradiol and testosterone increased significantly. Since the age of 6 months, the patient had taken food added with a large amount of chicken essence seasoning (a flavoring in Chinese cooking), with an average of 15 g of this seasoning a day. A kind of phytosterol (C29H48O) was detected in chicken essence seasoning by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS). After avoidance of the chicken essence seasoning, the patient's sex hormone levels decreased, all clinical symptoms returned to normal, and no further development of secondary sexual characteristics was detected.

CONCLUSION

This phytosterol-containing diet may be responsible for the sexual development of this patient. However, the mechanism of how phytosterols affect the process of development in children needs to be further explored.

Possible adrenal insufficiency among fatigue patients in a psychosomatic medical clinic

Fatigue is a common symptom in patients visiting the clinic of psychosomatic medicine. A 250-μg synthetic ACTH (1-24) test (rapid ACTH test) and Beck depression inventory (BDI) were performed for 62 patients presenting with fatigue who visited the Department of Psychosomatic Medicine at Fukuoka Tokushukai Hospital. Patients were divided into 3 groups according to the serum cortisol response to the rapid ACTH test; those with a peak serum cortisol level of <15 μg/dL were defined as the adrenal insufficiency (AI) probable group, ≥15 μg/dL and <18 μg/dL as the AI suspected group, and ≥18 μg/dL as the non-AI group. Patients prescribed anti-depressants, had a BDI ≥16, and/or met the full criteria for major depression were diagnosed with depression. Five (8.0%) and 7 patients (11.3%) were assigned to the AI probable and AI suspected groups, respectively. All others were assigned to the non-AI group. Depression was observed in 37 patients (59.6%; 4 in the AI probable group [80.0%], 4 in the AI suspected group [57.1%], and 29 in the non-AI group [58.0%]). Users of exogenous steroids, such as inhaled steroids for bronchial asthma, were seen in the AI probable group (2; 40.0%), the AI suspected group (3; 42.8%), and the non-AI group (7; 14.0%) (χ² = 4.761, p = 0.0925). In conclusion, probable or suspected AI was observed in about one-fifth of patients presenting with fatigue at the psychosomatic medical clinic. A CRH test and insulin tolerance test (ITT) may help the he mechanism underlying these possible AIs.