Refractory Cushing’s Disease Complicated by Severe Thrombocytopenia and Pituitary Apoplexy Culminating in a Fatal Outcome: A Case Report

Hypercortisolemia associated with Cushing's disease is classically recognized as a hypercoagulable state.Conversely, severe thrombocytopenia and hemorrhagic complications are exceptionally rare presentations.We report a case of a 59-year-old woman who presented with headache, proximal weakness, and Cushingoid features.Examination revealed severe Cushingoid features.Laboratory findings showed metabolic alkalosis, severe hypokalemia, and mild thrombocytopenia.Biochemical evaluation confirmed adrenocorticotropic hormone (ACTH)-dependent hypercortisolism (cortisol 157 µg/dL, ACTH 212 pg/mL), and a magnetic resonance imaging (MRI) scan revealed a 28-mm invasive pituitary macroadenoma extending into the sphenoid sinus and left cavernous sinus.The patient was admitted to the intensive care unit for electrolyte replacement and blood pressure control.Thrombocytopenia worsened progressively alongside mucocutaneous bleeding.Diagnostic workup showed preserved megakaryopoiesis, normal ADAMTS-13 activity, absent schistocytes, and elevated factor VIII and von Willebrand factor levels, pointing toward platelet consumption driven by severe endothelial stress.Given severe tissue fragility and progressive thrombocytopenia, transsphenoidal surgery was deferred, and medical therapy with cabergoline, mifepristone, and metyrapone was initiated.However, dose escalation was halted by worsening hypokalemia and refractory symptoms.The patient developed central diabetes insipidus (DI), necessitating desmopressin.On day 29, acute neurological deterioration with a left third cranial nerve palsy occurred; repeat neuroimaging confirmed acute pituitary apoplexy.Emergency transsphenoidal decompression was deferred due to profound thrombocytopenia and carotid artery encasement.Facing refractory disease, salvage bilateral laparoscopic adrenalectomy was performed on day 31.Postoperatively, the patient developed refractory shock, ischemic hepatitis, and anuric acute kidney failure.Despite multimodal medical therapy, she succumbed to multiorgan failure on day 35.This case illustrates a rare and life-threatening presentation of Cushing's disease complicated by suspected secondary consumptive thrombocytopenia and sellar apoplexy, highlighting the critical challenges of managing fulminant hypercortisolemia when emergency neurosurgical intervention carries prohibitive operative risks.This case underscores the locally invasive behavior of some pituitary tumors and the need for multidisciplinary management of severe Cushing's disease complications.