Table 4

 Some relatively specific clinical characteristics of Cushing’s syndrome

DEXA, dual energy x ray absorptiometry.
• Proximal myopathy: present in only 20% of patients, but a relatively specific sign best elicited by asking patients to stand from sitting without using their hands; standing from squatting is impaired in simple obesity
• Centripetal fat distribution: the fat pad over the upper back and filling in of the temporal and supraclavicular fossae is more typical of hypercortisolaemia than simple obesity
• Neuropsychiatric symptoms: impairment of short term memory and exaggeration of premorbid personality traits; happy people become very happy and vice versa
• Striae: present in simple obesity, but dark purple striae 1 cm across, distributed over the buttocks, arms, and breasts as well as the lower abdomen, suggest hypercortisolaemia
• Easy bruising: patients often acknowledge this when asked but bruises are rarely evident in clinic
• Skin thinning: this is not prominent in pituitary dependent Cushing’s as ACTH driven adrenal androgen production is protective
• Hirsutism: hypercortisolaemia is associated with hypertrichosis—that is, increased hair growth located in non-androgen dependent areas, as well as androgen dependent (male pattern) hirsutism
• Osteopenia, if demonstrable on DEXA scanning, may help distinguish hypercortisolaemia from obesity, where bone mineral density tends to be well preserved.