Case Study - Investigating an unusual cause of falls

Falls, nausea and unexplained pain were the result of an elderly woman's breast cancer, writes Dr Keith Barnard.

Violet was 78 and, despite her type-2 diabetes, she was active and in good spirits. Therefore, when I received a phone call from a neighbour to say that she was unwell, I knew that I should be concerned.

When I called on her, she was sitting in a chair. She had felt unwell for two or three weeks, and said she had vomited. Her main complaint was postural dizziness and she admitted she had fallen twice.

Her blood sugar was normal, but her BP was on the low side.

On examination, her abdomen, chest and breasts were normal. Neurological examination revealed nothing untoward. She had tanned skin which I attributed to her love of gardening.

Tests arranged

I arranged an ECG and blood tests, which were all normal, though her sodium was a bit low at 123mmol/l, while her potassium was normal.

When I followed her up two days later with the results, she said she was feeling better, so I was surprised when I heard that over the weekend she had been admitted to hospital, having been found unconscious at home.

I was afraid I had missed something important and spoke to her consultant the next day, who reassured me that they too were mystified.

I kept a track on her progress, and was told that she had become listless, followed by developing shortness of breath with a small pleural effusion that appeared on a chest X-ray.

Tests revealed low sodium at 120mmol/l, potassium at 5.4mmol/l and an early morning cortisol level of 230nmol/l. A short synacthen test showed no rise in cortisol levels.

This probably explained why I thought she had a tan.

Violet came home from hospital three weeks later, but it was not until I got the consultant's letter that I heard that a CT scan had shown bilateral adrenal masses that were thought to be metastatic carcinoma. No primary tumour had been found in the chest, kidneys, liver or large bowel and a mammogram was normal. However, a needle biopsy revealed a carcinoma of the breast.

Despite having this rare form of adrenal failure from the metastases, Violet has done well and continues to take fludrocortisone and tamoxifen, as well as treatment for her type-2 diabetes.

However, the next time an elderly person starts having falls, I will think that little bit harder.

- Dr Barnard is a former GP in Fareham, Hampshire.

LESSONS LEARNT

- Anorexia, nausea, vomiting, diarrhoea, dizziness and syncope can all occur in primary adrenal insufficiency.

- Other causes of destruction of the adrenal gland include tuberculosis, fungal infection or haemorrhage.

- Adrenal failure due to primary tumours of the adrenal glands is rare.

- However, adrenal metastases are common in patients with cancer, and at post-mortem 30 per cent of patients with primary cancers have them.

- Tumours that commonly metastasise to the adrenal glands include bronchus, breast, melanoma, kidney, liver and large bowel.

- It is not unknown for patients with breast tumours to have no obvious evidence of cancer on examination or on mammography.

- Always look out for malignancy in unexplained symptoms in the elderly.

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