Navigating the complexities of severe Cushing's syndrome in the ICU: a case report.

Severe Cushing's syndrome (SCS) is a rare but potentially fatal endocrine emergency. We describe a woman in her fifties with a history of pituitary macroadenoma who presented with mood disturbance, proximal muscle weakness, and Cushingoid features. On admission to the intensive care unit (ICU) she was febrile, hypoxic, hypotensive, and disoriented, with imaging prior confirming recurrent pituitary macroadenoma and biochemical tests showing severe hypercortisolism. She was managed with intravenous etomidate, starting with a bolus followed by titrated infusion, which achieved rapid cortisol suppression. A block-and-replace strategy was then implemented, introducing physiological hydrocortisone once cortisol levels fell to the target range. Broad spectrum antimicrobial therapy and organ support were provided. Although biochemical control was achieved, her course was complicated by ventilator-associated pneumonia with multidrug-resistant organisms, culminating in refractory septic shock and death. This case underlines the diagnostic challenges of recognizing SCS in sepsis and the clinical value of etomidate-based block-and-replace therapy.