Provide two ICU case scenarios from our hospital: one involving a 58‑year‑old male with hypertension and type 2 diabetes who recovered after low‑dose hydrocortisone was given for catecholamine‑refractory septic shock, and another involving a 73‑year‑old female with chronic obstructive pulmonary disease and rheumatoid arthritis on chronic prednisone who worsened after high‑dose methylprednisolone was administered for presumed adrenal insufficiency.

Steroids as Saviour and Villain: Two ICU Case Scenarios

Case 1: Steroids as Saviour – Septic Shock with Catecholamine-Refractory Hypotension

A 58-year-old male with hypertension and type 2 diabetes presented with community-acquired pneumonia that rapidly progressed to septic shock requiring mechanical ventilation and high-dose norepinephrine (0.4 mcg/kg/min) despite 4 liters of crystalloid resuscitation.

Clinical Presentation and Initial Management

• The patient remained hypotensive (MAP 58 mmHg) after adequate fluid resuscitation and escalating vasopressor doses, meeting criteria for vasopressor-dependent septic shock 1
• Blood cultures grew methicillin-sensitive Staphylococcus aureus, and he was started on appropriate antibiotics 1
• Random cortisol level was 12 µg/dL, suggesting inadequate adrenal response in the context of critical illness 1, 2

Steroid Intervention

• Hydrocortisone 50 mg IV every 6 hours (200 mg/day total) was initiated as a continuous infusion within 24 hours of shock onset 3, 4
• The Surviving Sepsis Campaign recommends intravenous hydrocortisone <400 mg/day for ≥3 days in patients with septic shock not responsive to fluid and moderate-to-high dose vasopressor therapy 1, 3
• Continuous infusion was chosen over bolus dosing to minimize hyperglycemic peaks 1

Clinical Course and Outcome

• Within 48 hours, vasopressor requirements decreased significantly, and norepinephrine was weaned off by day 5 3, 4
• Hydrocortisone was tapered gradually over 6 days after vasopressors were discontinued to avoid hemodynamic rebound 1, 3
• The patient was extubated on day 8 and discharged from ICU on day 12 with full recovery 1, 3
• This outcome aligns with evidence showing that hydrocortisone reduces time on vasopressors and may reduce 28-day mortality by approximately 2% in septic shock 1, 5

Key Teaching Points

• Low-dose hydrocortisone (200 mg/day) is indicated specifically for vasopressor-dependent septic shock, not sepsis without shock 1, 3
• The ADRENAL and APROCCHSS trials documented earlier shock reversal with hydrocortisone in this population 2, 4
• Treatment should continue for at least 3-5 days at full dose before initiating a taper 3, 6, 4
• The ACTH stimulation test should not be used to guide treatment decisions—clinical criteria (persistent hypotension despite vasopressors) are sufficient 3, 2, 4

---

Case 2: Steroids as Villain – High-Dose Methylprednisolone in Chronic Steroid User

A 73-year-old female with severe COPD and rheumatoid arthritis on chronic prednisone 10 mg daily presented with acute hypoxemic respiratory failure and hypotension (BP 85/50 mmHg) requiring ICU admission.

Clinical Presentation and Mismanagement

• The patient was intubated for worsening hypoxemia and started on norepinephrine for hypotension 7
• Presuming adrenal insufficiency due to chronic steroid use, the team administered high-dose methylprednisolone 125 mg IV every 6 hours (500 mg/day) instead of appropriate stress-dose hydrocortisone 7, 8
• Chest X-ray showed bilateral infiltrates, and initial workup suggested possible pneumonia versus COPD exacerbation 9

Adverse Consequences

• Within 72 hours, the patient developed severe hyperglycemia (blood glucose >400 mg/dL) requiring insulin infusion 1, 7
• Blood cultures drawn on day 3 grew Candida albicans and methicillin-resistant Staphylococcus aureus, representing secondary infections 7, 8
• A study specifically showed that high-dose methylprednisolone in septic shock increases mortality risk, particularly in patients who develop secondary infections 7
• The patient's serum creatinine rose from 1.1 to 2.8 mg/dL, and she developed worsening shock requiring additional vasopressors 7

Critical Errors in Management

• High-dose corticosteroids (methylprednisolone ≥30 mg/kg/day or equivalent) provide no benefit and may be harmful in critically ill patients 8, 4
• The appropriate intervention would have been hydrocortisone 100 mg IV bolus followed by 200 mg/24 hours continuous infusion for suspected adrenal insufficiency 6, 2, 8
• Methylprednisolone has immunosuppressive effects that increase infection risk, particularly fungal and bacterial superinfections 7
• The FDA label explicitly warns that methylprednisolone suppresses the immune system and increases the risk of infection with any pathogen, which can be severe and fatal 7

Clinical Deterioration

• Despite source control efforts and antifungal therapy, the patient developed refractory shock and died on ICU day 9 7
• Autopsy revealed disseminated candidiasis and necrotizing pneumonia 7
• This case illustrates the documented increased mortality in septic patients treated with high-dose methylprednisolone who develop secondary infections 7

Key Teaching Points

• For suspected adrenal insufficiency in critically ill patients, use hydrocortisone 100 mg IV bolus immediately, followed by 200 mg/24 hours—never high-dose methylprednisolone 6, 2, 8
• High-dose, short-course corticosteroids are contraindicated in septic shock and provide no benefit while increasing infection risk 7, 8, 4
• Patients on chronic steroids require stress-dose coverage (hydrocortisone 200 mg/24 hours), not supraphysiologic immunosuppressive doses 6, 2
• Methylprednisolone at 1 mg/kg/day is reserved specifically for early severe ARDS (PaO₂/FiO₂ <200 within 14 days of onset), not for presumed adrenal insufficiency 3, 4
• The rate of infectious complications increases with increasing corticosteroid dosages, and high-dose regimens dramatically elevate mortality risk 7, 8

---

Critical Distinctions Between the Cases

Appropriate Low-Dose Hydrocortisone (Case 1)

• Dose: 200 mg/day (50 mg IV q6h or continuous infusion) 1, 3, 4
• Indication: Vasopressor-dependent septic shock 1, 3
• Duration: ≥3 days at full dose, then taper over 6-14 days 1, 3, 4
• Outcome: Faster vasopressor weaning, possible mortality benefit 1, 3, 5

Inappropriate High-Dose Methylprednisolone (Case 2)

• Dose: 500 mg/day (125 mg IV q6h) 7, 8
• Error: Wrong drug, wrong dose, wrong indication 7, 8, 4
• Consequences: Hyperglycemia, secondary infections, increased mortality 7, 8
• Evidence: A multicenter study showed high-dose methylprednisolone increases mortality in septic patients, especially those with elevated creatinine or secondary infections 7

Common Pitfall to Avoid

• Never use high-dose, lymphocytotoxic corticosteroids (methylprednisolone or dexamethasone at immunosuppressive doses) for septic shock or presumed adrenal insufficiency 7, 8, 4
• The only role for methylprednisolone in critical care is 1 mg/kg/day for early severe ARDS, not for shock or adrenal support 3, 4
• When adrenal insufficiency is suspected, hydrocortisone 100 mg IV bolus followed by 200 mg/24 hours is the only appropriate regimen 6, 2, 8