BACKGROUND We describe a previously healthy 40-year-old woman with Cushing's syndrome caused by adrenocorticotropic hormone (ACTH) secretion from metastatic carcinoid. METHODS Over a 2-year period, the patient had multiple hospitalizations for uncontrolled hypertension, hyperglycemia, and hypokalemia. She had transient flushing, rashes, and a rapid weight gain. In addition, she developed anasarca and had a nontraumatic hip fracture 1 month before presentation. Subsequently, a hypertensive crisis resulted in admission to the intensive care unit and fine-needle aspiration of a liver lesion. CONCLUSIONS A diagnosis of metastatic carcinoid was established. She was transferred to our hospital for further evaluation and management. On arrival, she had the signs of Cushing's syndrome. Despite extensive evaluation, her primary carcinoid tumor was not localized. She was treated successfully with bilateral adrenalectomy and octreotide. CONCLUSIONS This case illustrates how early recognition of the signs and symptoms of excess ACTH is important for prompt and appropriate treatment.