Cushing's syndrome

The clinical syndrome of glucocorticoid excess. This may be caused by exogenous steroid use, ACTH independent adrenal disease, or ectopic ACTH. The diagnosis Cushing's disease specifically refers to Cushing's caused by ACTH secreting tumours of the pituitary gland.

General examination

To diagnose Cushing's syndrome a detailed and full general examination is mandatory in the initial assessment of all patients.

Blood pressure

Elevated BP may not have been previously noted.

BMI

Baseline recording is useful.

Body habitus

Waist hip ratio is typically increased, with peripheral wasting and central obesity being typical findings. This is very important to record and ideally should be photographed.

Skin: bruising, thinning, pigmented striae, acanthosis nigricans, pigmentation

Gently pinch the skin on the back of the hand to seek the fine wrinkling of thinned atrophic skin. Extensive bruising, for example from venepuncture, should be sought. 

Striae are common and should fade soon after forming, for example at times of rapid growth: puberty or pregnancy. In Cushing’s, the striae remain livid - purple or red and are often extensive. 

Acanthosis nigricans is indicative of insulin resistance of any cause. New pigmentation is suggestive of high levels of ACTH typically from an ectopic source.

Myopathy

One of the most sensitive tests is to ask the patient to squat on the floor with their heels flat on the ground. While demonstrating the same thing, ask the patient to then rise to a standing position without using their arms for support or swinging their bottom up and out first. 

More severe myopathy will be evident by asking the patient to rise from a chair without using their arms for support.

Virilisation

Examine the musculature for increased bulk in women. Examine for changes in secondary sexual characteristics, for hirsutism and for clitoromegaly.