What are the symptoms of adrenal insufficiency in an elderly woman with non-invasive (ductal carcinoma in situ) breast cancer?

Symptoms of Adrenal Insufficiency in Elderly Women with Non-Invasive Breast Cancer

Adrenal insufficiency presents with profound fatigue, unintentional weight loss, anorexia, postural hypotension, muscle weakness, gastrointestinal symptoms (nausea, vomiting, abdominal pain), and hyponatremia, with skin hyperpigmentation and salt craving being specific indicators of primary adrenal failure. 1

Cardinal Symptoms to Assess

Constitutional Symptoms

• Profound fatigue and easy fatigability that is disproportionate to activity level and does not improve with rest 2, 3, 1
• Unintentional weight loss despite adequate caloric intake 2, 1
• Anorexia with progressive loss of appetite 3, 1
• Generalized muscle weakness affecting daily activities 3, 4

Cardiovascular Manifestations

• Postural hypotension with dizziness upon standing 1
• Persistent low blood pressure that may be refractory to standard management 3, 4
• Orthostatic symptoms including lightheadedness and near-syncope 1

Gastrointestinal Symptoms

• Nausea and vomiting that may be intermittent or persistent 3, 1
• Abdominal pain that can be diffuse or cramping in nature 1
• Nonspecific gastrointestinal complaints that mimic other conditions 2

Dermatologic Findings (Primary Adrenal Insufficiency Only)

• Skin hyperpigmentation particularly in sun-exposed areas, skin creases, palmar creases, buccal mucosa, and recent scars—this is pathognomonic for primary adrenal failure 2, 3, 1
• Salt craving as a behavioral manifestation of mineralocorticoid deficiency 1

Laboratory Abnormalities

• Hyponatremia (low sodium) is a hallmark finding 3, 1
• Hyperkalemia (elevated potassium) in primary adrenal insufficiency 3
• Hypoglycemia particularly in acute presentations 5

Critical Context for Elderly Women with Breast Cancer

Diagnostic Challenges

• Symptoms overlap significantly with cancer-related fatigue, chemotherapy side effects, and general debility from malignancy, making diagnosis particularly challenging and often delayed 2, 3
• The nonspecific nature of symptoms means physicians must maintain high clinical suspicion, especially in patients with bilateral adrenal involvement or those on chronic glucocorticoid therapy 2, 1

High-Risk Scenarios Requiring Immediate Evaluation

• Any acute clinical deterioration with hypotension, fever, altered mental status, or declining consciousness should trigger immediate evaluation for adrenal crisis, even before laboratory confirmation 3
• Patients with bilateral adrenal metastases (though rare in non-invasive breast cancer) require screening for adrenal insufficiency when presenting with the above symptoms 5
• History of autoimmune disease (hypothyroidism, diabetes) increases suspicion for autoimmune adrenal insufficiency 3
• Recent or current use of exogenous corticosteroids or opioid medications can suppress adrenocorticotropic hormone and cause secondary adrenal insufficiency 1

Primary vs. Secondary Adrenal Insufficiency Distinction

• Primary adrenal insufficiency (Addison disease) presents with hyperpigmentation, salt craving, hyperkalemia, and elevated ACTH—most commonly autoimmune in etiology 2, 4
• Secondary adrenal insufficiency results from pituitary/hypothalamic disorders or exogenous glucocorticoid suppression and lacks hyperpigmentation, salt craving, and hyperkalemia 2, 4

Clinical Pitfalls to Avoid

• Do not attribute all fatigue, weight loss, and weakness to cancer or aging alone—these symptoms warrant specific evaluation for adrenal insufficiency when accompanied by hypotension or electrolyte abnormalities 2, 1
• Do not delay treatment while awaiting laboratory confirmation if acute adrenal crisis is suspected based on clinical deterioration 3
• Do not overlook subtle hyperpigmentation in elderly patients with fair skin or limited sun exposure—examine palmar creases, buccal mucosa, and areas of friction 2, 1