cushing 's syndrome ( cs ) is a general term for a cluster of endocrine abnormalities characterized by chronic cortisol overproduction . characteristic clinical comorbidities include metabolic complications ( e.g. , visceral obesity , diabetes mellitus , and dyslipidemia ) , cardiovascular complications ( e.g. , systemic arterial hypertension , atherosclerosis , and thromboembolism ) , bone complications ( e.g. , osteoporosis and osteoarthritis ) infective complications , and neuropsychiatric disorders ( e.g. , major depression , mania , anxiety , and cognitive impairment ) . cs may be exogenous and iatrogenic due to corticosteroid administration or endogenous due to excessive acth secretion , most commonly from a pituitary adenoma , referred to , somewhat confusingly , as cushing 's disease , or less commonly from a nonpituitary tumor ( ectopic cs ) and primary adrenal neoplasms . this report describes the case of a 60-year - old carcinoid patient with cognitive impairment due to hypercortisolism from cs who developed bacteremia ; his condition deteriorated , and he died after a decision was made to withdraw care . a 60-year - old male with metastatic bronchopulmonary neuroendocrine tumor treated on a clinical trial for over 5 months was admitted to the hospital with complaints of fever , agitation , and weakness . his medical history was significant for newly diagnosed cs secondary to acth secretion ; he had been hospitalized 2 weeks earlier for cs - induced hyperglycemic crisis . on admission , the patient presented with classic cushingoid habitus of facial plethora , moon facies , muscle atrophy , abdominal striae , and truncal obesity . the arterial blood gas analysis on room air was ph 7.497 , paco2 29 mm hg , pao2 71 mm hg , and oxygen saturation 95% . as respiratory failure was imminent , he was transferred to the intensive care unit and mechanically ventilated . the highest positive end - expiratory pressure and fio2 required to maintain oxygenation were 5 cm h2o and 50% , respectively . cultures were taken from bronchial secretions directly after endotracheal intubation and from urine and blood . the patient was diagnosed with staphylococcus aureus bacteremia , and based on susceptibility testing , he was started on vancomycin and zosyn . in addition to antibiotics , the patient received lisinopril for cs - induced hypertension and insulin sliding scale to control hyperglycemia . since high circulating levels of glucocorticoids due to ectopic acth secretion predispose to infection and impair immune function and clearance of bacteria , the immediate plan was to start him on mifepristone ( 600 mg daily ) as a glucocorticoid receptor antagonist to counteract the immunosuppressive and cognitive effects of the endogenous hypercortisolism . as soon as the patient 's condition improved ( which would have been expected given the known reversibility of hypercortisolism ) , cytoreductive chemotherapy would have been restarted to reduce the paraneoplastic stimulus . however , the patient 's family with medical power of attorney refused consent and withdrew him from the ventilator . advance directives are written to guarantee autonomy in the event that individual decision - making capacity is lost due to disease severity or treatment . however , as a blanket statement that may contain overly broad ( or overly specific ) prewritten blocks of text , especially for cancer patients , the content of advance directives may or may not necessarily apply to and/or the patient 's wishes may or may not be correctly interpreted during acute , temporary and potentially reversible conditions that occur during cancer treatment such as infection due to ectopic cs . given the potential for cognitive impairment and other acute sequelae such as difficult - to - treat infections from the development of ectopic cs , this case illustrates the importance of revisiting the advance directive when a medical diagnosis associated with temporary cognitive impairment such as cs is made .
glucocorticoids are associated with immunosuppression and neuropsychiatric complications . 
 we describe the case of a carcinoid patient with cushing 's syndrome ( cs ) and neurocognitive impairment due to ectopic acth production who developed sepsis and died because of his family 's decision to withdraw antibiotic treatment . 
 this report is presented to illustrate the importance of advanced - care planning in patients with cs .