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Cushing's Syndrome OSCE Examination Quiz

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On inspecting the chest and abdomen of a patient with suspected Cushing's syndrome, which finding most specifically reflects the combination of thin skin and central fat accumulation caused by excess cortisol?

A Generalised thinning of the abdominal skin with visible underlying veins
B Wide purple stretch marks (striae) across the abdomen and flanks ✓
C Excess dark hair across the lower abdomen and inner thighs from adrenal androgens
D Acanthosis nigricans in the skin folds of the abdomen and axillae from insulin resistance
E A rounded, protuberant abdomen from deposition of fat in the abdominal wall and omentum

The answer is B: Wide purple stretch marks (striae) across the abdomen and flanks

Explanation

Why B is correct

See Chest and Trunk. Option B is correct. Excess cortisol has two effects that combine on the trunk. It makes the skin thin and fragile, because cortisol inhibits fibroblasts (the cells that make collagen, the protein that gives skin its strength) and so reduces collagen, and it makes fat accumulate centrally, on the abdomen and trunk. When the weakened skin is stretched over the enlarging fat deposits it tears, exposing the blood-rich layer beneath (the vascular dermis), and the result is striae: broad, purple or violaceous stretch marks across the abdomen and flanks. Their breadth, often more than 1 cm, and their dark colour help to separate them from the pale, narrow striae of ordinary weight gain or pregnancy. A plain-language aid: thin skin plus a growing middle means the skin tears, and the blood underneath shows through as purple.

Skin: Cortisol inhibits fibroblasts and reduces collagen, so the skin is thin and fragile.
Fat: It accumulates centrally, on the abdomen and trunk.
Sign: Broad, purple striae appear where the weakened skin tears over the fat deposits.

Why the other options are incorrect

A. Generalised thinning of the abdominal skin with visible underlying veins: Thin, translucent abdominal skin with visible veins reflects cortisol-induced skin atrophy. It shows only one half of the asked combination and does not indicate central fat accumulation.
C. Excess dark hair across the lower abdomen and inner thighs from adrenal androgens: Abdominal and thigh hirsutism is caused by adrenal androgen excess in Cushing syndrome. It is an endocrine skin change and does not reflect the combined skin thinning and central fat mechanism in the stem.
D. Acanthosis nigricans in the skin folds of the abdomen and axillae from insulin resistance: Acanthosis nigricans is a skin sign of insulin resistance, which cortisol excess can cause. It is not produced by the combination of thin skin and central fat and is therefore off-target.
E. A rounded, protuberant abdomen from deposition of fat in the abdominal wall and omentum: A rounded abdomen reflects central fat accumulation alone. It does not show the combination of thin skin stretched over that fat, so it does not answer the stem.

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1
Having examined a patient for suspected Cushing's syndrome, which set of actions is the most appropriate way to round off the assessment?
2
A 29-year-old woman is assessed for suspected Cushing's syndrome. She has a rounded, flushed (plethoric) face, acne, coarse hair on the upper lip and darkening of the lining of the mouth (buccal mucosa). Testing her visual fields suggests that she has lost the outer half of vision in both eyes. Which mechanism best explains this?

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