Overt Cushing

Malgorzata M. Lubczynska; Haider Imtiaz; Abdul Paracha; Emma Bremner; Mary Barrowcliffe; Narendra Reddy; Shailesh Gohil; Amy E. Morrison; Miles J. Levy

doi:10.1530/endoabs.117.P34

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Endocrine Abstracts (2026) 117 P34 | DOI: 10.1530/endoabs.117.P34

SFEBES2026 Poster Presentations Adrenal and Cardiovascular (54 abstracts)

Overt Cushing’s Disease in the ICU: Key Considerations and Challenges

Malgorzata M. Lubczynska ¹ , Haider Imtiaz ¹ , Abdul Paracha ¹ , Emma Bremner ¹ , Mary Barrowcliffe ¹ , Narendra Reddy ^1,2 , Shailesh Gohil ^1,2 , Amy E. Morrison ^1,2 & Miles J. Levy ^1,2

Author affiliations

¹University Hospitals of Leicester, Leicester, United Kingdom; ²University of Leicester, Leicester, United Kingdom

Background: Cyclical Cushing’s syndrome can present with dramatic swings in cortisol, posing diagnostic and therapeutic challenges. Critically ill patients may develop severe metabolic, cardiovascular, and infectious complications. Rapid control of hypercortisolism is essential to stabilize patients and prepare for definitive therapy, yet oral medications may be poorly tolerated in unstable cases.

Case Presentation: We describe a 51-year-old woman presenting with seizure-like activity, behavioural changes, and refractory hypokalaemia (2.7 mmol/l). Biochemistry confirmed ACTH-dependent hypercortisolism (serum cortisol >1749 nmol/l, ACTH 182 pmol/l, urinary free cortisol >1900 nmol/24h), but imaging and inferior petrosal sinus sampling failed to localize a source. Her hospital course was complicated by colonic perforation requiring emergency surgery, postoperative diabetes, psychosis, and severe Klebsiella pneumoniae pneumonia leading to septic shock. Persistent cortisol excess contributed to profound metabolic instability despite oral therapy. She required ICU transfer for refractory hypercortisolaemia and hypokalaemia. Continuous intravenous etomidate (0.04 mg/kg/hr) was started, achieving rapid cortisol reduction within 24 hours. Serial serum and salivary cortisol guided titration, and hydrocortisone supplementation prevented adrenal insufficiency. While metabolic parameters improved, overwhelming infection ultimately proved fatal.

Discussion: Management of severe Cushing’s in the ICU must balance haemodynamic stabilization, metabolic correction, infection control, and thromboprophylaxis. Etomidate is uniquely valuable for rapid parenteral cortisol suppression but demands vigilant monitoring due to its narrow therapeutic window. Its use is best viewed as a short-term bridge to oral steroidogenesis inhibitors or definitive surgery.

Conclusion: This case highlights the diagnostic complexity of cyclical Cushing’s and underscores the importance of multidisciplinary ICU care. Etomidate can be life-saving for acute hypercortisolism, but careful titration, monitoring, and transition planning are essential for optimal outcomes.