SUN-479 - Steroid-Related Hypothalamic-Pituitary-Adrenal Axis Dysfunction and Neurocognitive Toxicity Presenting as Delirium in A Critically Ill Patient with Pemphigus Foliaceus

Background
Systemic glucocorticoids are first-line therapy for severe autoimmune blistering diseases, including pemphigus foliaceus. Advanced age, high cumulative steroid exposure, critical illness, and sepsis increase the risk of neurocognitive complications, including delirium. In critically ill patients, these may present atypically and are often multifactorial. Recognition is especially challenging in resource-limited settings, where dynamic adrenal testing is limited, necessitating clinical endocrine reasoning.

Case Presentation
An 82-year-old man with hypertension and newly diagnosed severe pemphigus foliaceus was transferred for progressive skin sloughing and suspected sepsis. Outpatient prednisone was escalated to intravenous methylprednisolone 75 mg daily. His course was complicated by multidrug-resistant Acinetobacter baumannii bacteremia, systemic inflammation, and metabolic stress.

During the second week of hospitalization, he developed acute delirium with fluctuating attention and agitation. Head CT revealed chronic involutional changes without acute pathology. Laboratory evaluation showed preserved sodium and potassium, hypoalbuminemia, and marked glycemic variability (50–357 mg/dL). Infectious parameters were improving.

Delirium was considered multifactorial, with contributions from advanced age, severe sepsis, metabolic stress, and high-dose glucocorticoids. Endocrinology consultation guided steroid continuation and coordinated glycemic management. The patient ultimately succumbed to multiorgan failure related to severe sepsis, with neurocognitive complications contributing to clinical complexity but not serving as the primary cause of death.

Discussion
Glucocorticoids influence CNS signaling, circadian cortisol rhythms, and glucose metabolism, potentially contributing to delirium. In critically ill older adults, delirium is often multifactorial. Preserved electrolytes were expected given supraphysiologic steroid dosing. Early recognition and endocrine-guided management of metabolic and neurocognitive complications are essential to optimize outcomes, particularly in resource-limited settings.

Conclusion
Delirium in critically ill patients with autoimmune disease receiving systemic glucocorticoids should be recognized as multifactorial. Future research should investigate predictive markers of steroid neurotoxicity, glucocorticoid-sparing therapy, and ICU protocols for endocrine-guided care to mitigate fatal outcomes.

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