Metastatic Breast Cancer: A Rare Cause of Adrenal Crisis

Presentation Number: SUN 373
Date of Presentation: April 2nd, 2017

Samantha Tan*, Mohamad Rachid, Irfan Siddiqui and Tahira Yasmeen
Advocate Christ Medical Center, Oak Lawn, IL

Abstract

Introduction: Metastases to the adrenal glands are common in patients with malignancy but adrenal crisis is rare. Lung and breast cancer usually metastasize to the adrenal glands, however, these rarely cause any overt clinical symptoms.

Clinical Case: A 58 year old woman with breast cancer presented to the emergency department with complaints of uncontrollable left leg twitching and weakness of the left leg. Physical examination was remarkable for hyperpigmentation of the dorsum of both hands, minimal left lower extremity edema and decreased strength of the left lower extremity. There was concern for a new metastatic lesion to the brain. A head CT scan revealed a lesion in the right frontal region. There was suspicion for a focal seizure, and she was loaded with dilantin. She was later noted to be diaphoretic, less responsive and hypotensive. Laboratory results revealed hyponatremia (126 mmol/L) and hyperkalemia (6.5 mmol/L). ECG did not show ischemic changes or changes consistent with hyperkalemia. She developed hypoglycemia after receiving 10 units of insulin with dextrose. Fingerstick blood glucose was 55, and she was given an ampule of D50. Adrenal insufficiency was suspected because of the presentation of hypotension, hyponatremia and hyperkalemia despite normal renal function. She received 10 mg of IV dexamethasone. A random cortisol level drawn at that time was low (2.7 mcg/dL). She was started on dexamethasone and fludrocortisone. ACTH level drawn the next day was not suppressed at 29 pg/mL (reference range: 4.2 to 42.9 pg/mL). Cortisol levels remained low at 30 and 60 minutes post-cosyntropin stimulation. A diagnosis of primary adrenal insufficiency was made. Imaging studies including a CT scan of the chest, abdomen and pelvis revealed bilateral adrenal masses, with densities not consistent with adrenal adenomas. The patient continued to improve, and vital signs stablized. Radiation treatment was planned for the brain lesion. She was discharged home with a regimen of dexamethasone and fludrocortisone, with arrangements for close follow up monitoring as outpatient.

Conclusion: We describe a case of a patient with breast cancer which metastasized to bilateral adrenal glands leading to adrenal crisis. It is important to have a high index of suspicion for adrenal insufficiency, especially in patients with metastatic lung or breast cancer, as its presentation can easily be missed.

 

Nothing to Disclose: ST, MR, IS, TY