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Graves Disease

Autoimmune Thyrotoxicosis

Graves disease is an autoimmune thyroid disorder characterized by hyperthyroidism, ophthalmopathy and goitre. The autoimmune process in Graves disease is influenced by a combination of environmental and genetic factors. The signs and symptoms of Graves' disease include insomnia, tremor, hyperactivity, hyperhidrosis, heat intolerance, weight loss despite increased appetite, diarrhea, frequent defecation, palpitations and muscle weakness. It is named after Robert James Graves, a British physician.


Presentation

The younger patients suffering from Graves’ disease usually present with the typical symptoms of thyrotoxicosis. Most of the symptoms are due to increased activation of the sympathetic system [5]. In the elderly age group, there may be no symptoms or only subtle ones.

Patients suffering from Graves' disease may have the following complaints on history:

Physical exam may demonstrate the following findings:

  • Thyroid gland: The thyroid gland is always diffusely enlarged and is non-tender. A bruit may be auscultated over it.
  • Integumentary system: The hair become fine. The skin is warm. There may be areas of hyperpigmentation on it. Pretibial myxedema is often present [7].
  • Opthalmologic findings: There may be lid retraction, lid lag, proptosis, ophthalmoplegia and loss of visual acuity and color vision. Eye findings are present in around 50% of the patients.
  • Limbs: The limbs may show clubbing and fine tremors. Proximal myopathy can also be seen in some cases.

Graves’ disease, if left untreated, results in a state of life threatening thyrotoxicosis which is known as thyroid storm [8]. Even with early recognition and aggressive therapy, the mortality of this condition is 20% [9]. It results in various complications including weight loss with catabolism of bone and muscle, cardiac complications and psycho-cognitive complications. Graves’ disease is also associated with dermopathy, ophthalmopathy and acropathy.

Generalized Lymphadenopathy
  • Justine Huart, Stéphanie Grosch, Christophe Bovy, Michel Moutschen and Jean-Marie Krzesinski , IgG4-related membranous glomerulonephritis and generalized lymphadenopathy without pancreatitis: a case report , BMC Nephrology , 18 , 1 , (2017) . Y.[doi.org]
Goiter
  • It is also unclear whether long-term prognosis differs between Graves' disease and toxic nodular goiter.[ncbi.nlm.nih.gov]
  • The data supported the rationale for the use of goiter dispersion formula in Graves' disease treatment.[ncbi.nlm.nih.gov]
  • In patients with GD without GO, we found lowered percentages of CD4 Foxp3 cells, as compared to nodular goiter 1.77 vs. 5.42% (p 0.0276).[ncbi.nlm.nih.gov]
  • In the absence of ophthalmopathy, the diagnosis is generally based on the association of hyperthyroidism and usually diffuse goiter confirmed with serum anti-TSHR autoantibodies (TRAbs).[ncbi.nlm.nih.gov]
  • In conclusion, Graves, patients commonly present with or may develop nodules (12.6%) and the majority of these are benign expressions of autoimmune changes and coexistent nodular goiter.[doi.org]
Weight Loss
  • The signs and symptoms of Graves' disease include insomnia, tremor, hyperactivity, hyperhidrosis, heat intolerance, weight loss despite increased appetite, diarrhea, frequent defecation, palpitations and muscle weakness.[symptoma.com]
  • Abstract A 25-year-old woman presented with jaundice, palpitation, and weight loss of 5 kg during a period of 2 weeks.[ncbi.nlm.nih.gov]
  • Abstract A 37-year-old housewife presented with generalised fatigue, palpitations and weight loss over the past 3 months. Physical examination revealed signs of hyperthyroidism. Thyroid function tests confirmed the presence of thyrotoxicosis.[ncbi.nlm.nih.gov]
  • \ ˈgrāvz- \ Definition of Graves' disease : a common form of hyperthyroidism that is an autoimmune disease characterized by goiter, rapid and irregular heartbeat, weight loss, irritability, anxiety, and often a slight protrusion of the eyeballs First[merriam-webster.com]
  • Abstract OBJECTIVE: A 61 years old woman presented with low grade fever and weight loss for a month.[ncbi.nlm.nih.gov]
Fatigue
  • Abstract A 46 year-old female patient presented to the hospital with ongoing and progressively increasing fatigue, severe nausea and vomiting, loss of appetite, constipation, palpitations and somnolence.[ncbi.nlm.nih.gov]
  • She suffered from thirst and fatigue for one month. Her serum calcium (a) levels were 19.0 mg/dL, and she was diagnosed with hypercalcemic crisis. Circulating levels of parathyroid and thyroid hormones were elevated.[ncbi.nlm.nih.gov]
  • CASE: A 33 year-old, 8-week pregnant woman with hypothyroidism, presents with a 2-week history of palpitations, sweating, nervousness and fatigue. Physical examination shows tachycardia (108 bpm), distal tremors and diffuse goiter.[ncbi.nlm.nih.gov]
  • Abstract A 37-year-old housewife presented with generalised fatigue, palpitations and weight loss over the past 3 months. Physical examination revealed signs of hyperthyroidism. Thyroid function tests confirmed the presence of thyrotoxicosis.[ncbi.nlm.nih.gov]
  • One week after the treatment, she presented with severe pain in the anterior neck with radiation to the angle of the jaw associated with fatigue, tremor and odynophagia.[ncbi.nlm.nih.gov]
Heat Intolerance
  • The signs and symptoms of Graves' disease include insomnia, tremor, hyperactivity, hyperhidrosis, heat intolerance, weight loss despite increased appetite, diarrhea, frequent defecation, palpitations and muscle weakness.[symptoma.com]
  • It is characterized by hyperthyroidism associated with goiter, heart palpitations, bulging eyes, sweating, heat intolerance, tremor, anxiety and weight loss.[kashilab.com]
  • Hallmarks of the condition are bulging eyes (exophthalmos) , heat intolerance, increased energy, difficulty sleeping, diarrhea and anxiety, although not all patients will exhibit bulging eyes. Symptoms can wax and wane over time.[livingwithgravesdisease.com]
  • Hallmarks of the condition are bulging eyes (exophthalmos), heat intolerance, increased energy, difficulty sleeping, diarrhea and anxiety, although not all patients will exhibit bulging eyes. Symptoms can wax and wane over time.[livingwithgravesdisease.com]
  • […] affecting more women than men, between the ages of 30 and 60. [2] [3] Graves’ disease accounts for 85% of all cases of hyperthyroidism. [4] Characteristics/Clinical Presentation Goiter, Exophthalmos, tremors, dermopaty, tachycardia with palpitations, heat[physio-pedia.com]
Fever
  • Abstract OBJECTIVE: A 61 years old woman presented with low grade fever and weight loss for a month.[ncbi.nlm.nih.gov]
  • PATIENT CONCERNS: A 26-year-old woman complained about recurrent fever, auricular chondritis, ocular inflammation, and arthritis. She had an 8-year drug intake of PTU for Graves disease.[ncbi.nlm.nih.gov]
  • Symptoms of this thyroid crisis include fever, vomiting, elevated heart rate, confusion and profuse sweating and requires immediate emergency attention. (Visited 15,868 times, 26 visits today) « Back to Glossary Index[aarda.org]
  • It was on a ward round Graves light-heartedly suggested to William Stokes that his epitaph should read: "He fed fevers."[web.archive.org]
Dyspnea
  • We report a 17-year-old male patient who presented with chest pain, dyspnea, and tachycardia. He was found to have diffuse ST-segment elevation consistent with pericarditis. At presentation, he was noted to have bilateral proptosis.[ncbi.nlm.nih.gov]
  • […] presentation A 40-year-old Caucasian American man with reactive arthritis, Graves' disease, type 2 diabetes mellitus, mitral valve prolapse, and Gilbert's disease was admitted with one month of progressive jaundice, fatigue, lightheadedness, and exertional dyspnea[casesjournal.biomedcentral.com]
Diarrhea
  • Though quite rare, this disease can also manifest with gastrointestinal symptoms such as dysphagia, heartburn, nausea, vomiting and diarrhea.[ncbi.nlm.nih.gov]
  • Increased energy (hyperactivity) Fatigue Unexplained weight loss Trouble sleeping Inability to tolerate heat Trouble concentrating in school Diarrhea Fast, pounding heartbeat Bulging eyes Irregular periods Shaking Hyperthyroidism can be treated by taking[cincinnatichildrens.org]
  • You may experience hair loss and diarrhea is common. Women may find that the menstrual flow will lighten and the time between periods grow longer. Depression can also enter the picture.[thyroid-info.com]
  • Hallmarks of the condition are bulging eyes (exophthalmos) , heat intolerance, increased energy, difficulty sleeping, diarrhea and anxiety, although not all patients will exhibit bulging eyes. Symptoms can wax and wane over time.[livingwithgravesdisease.com]
  • Hallmarks of the condition are bulging eyes (exophthalmos), heat intolerance, increased energy, difficulty sleeping, diarrhea and anxiety, although not all patients will exhibit bulging eyes. Symptoms can wax and wane over time.[livingwithgravesdisease.com]
Increased Appetite
  • Patients with Graves' disease may have some of the common symptoms such as anxiety, difficulty in sleeping, fatigue, muscle weakness, nervousness, hand tremors, frequent bowel movements, increased appetite, rapid and irregular heartbeat, weight loss,[melbournethyroidcentre.com.au]
  • Symptoms that can indicate whether you have Graves’ disease are: insomnia and hyperactivity hand tremor hair loss excessive sweating and heat intolerance weight loss despite increased appetite diarrhoea palpitations (heartbeat sensations that feel like[in.optelec.com]
  • Symptoms of Graves' disease may include: Swelling, bulging, or inflammation around the eyes Weight loss Restlessness or anxiety Increased appetite Rapid heart beat Changes in sex drive Fatigue and/or muscle weakness Frequent bowel movements Double vision[dartmouth-hitchcock.org]
  • Some of the more common symptoms include: Weight loss—despite increased appetite Anxiety, restlessness, tremors, irritability, difficulty sleeping (insomnia) Heat intolerance, sweating Chest pain, palpitations Shortness of breath, difficulty breathing[endocrineweb.com]
Tachycardia
  • We present the case of a previously well 43 year old woman who presented in supraventricular tachycardia and acute pulmonary edema and died despite treatment and without a diagnosis for cause of death.[ncbi.nlm.nih.gov]
  • Physical examination shows tachycardia (108 bpm), distal tremors and diffuse goiter. After biochemical confirmation of hyperthyroidism, her levothyroxine dose is reduced and finally interrupted.[ncbi.nlm.nih.gov]
  • We report a 17-year-old male patient who presented with chest pain, dyspnea, and tachycardia. He was found to have diffuse ST-segment elevation consistent with pericarditis. At presentation, he was noted to have bilateral proptosis.[ncbi.nlm.nih.gov]
  • Abstract We report the case of a 10-year-old girl treated with atenolol and carbimazole for tachycardia and hypertension associated with Graves' disease who developed symptomatic 2:1 heart block. 2:1 heart block resolved following cessation of atenolol[ncbi.nlm.nih.gov]
  • The generation of anti-TSHR antibodies, enlarged thyroid sizes (goiter), elevated serum thyroxine levels, retro-orbital fibrosis, and cardiac involvement (tachycardia and hypertrophy) were consistently observed over 9 months.[ncbi.nlm.nih.gov]
Hypertension
  • KEYWORDS: Graves’ disease; hyperthyroidism; pulmonary hypertension; pulmonary hypertensive crisis; thyroid storm[ncbi.nlm.nih.gov]
  • Abstract We report the case of a 10-year-old girl treated with atenolol and carbimazole for tachycardia and hypertension associated with Graves' disease who developed symptomatic 2:1 heart block. 2:1 heart block resolved following cessation of atenolol[ncbi.nlm.nih.gov]
  • Author information 1 Department of Medicine II, Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo, Japan.[ncbi.nlm.nih.gov]
  • […] infection, steroid withdrawal Presentation Symptoms heat intolerance weight loss hyperactive diarrhea hyperreflexia tachycardia , palpitations, arrhythmias thyroid hormone increases heart rate and contractility and decreases SVR warm moist skin and sweating hypertension[step2.medbullets.com]
  • Hypertension is also commonly seen with thyrotoxicosis. Orthostatic hypotension may occur, but may also indicate glucocorticoid deficiency with Addison’s disease.[endobible.com]
Mitral Valve Prolapse
  • A 40-year-old man with reactive arthritis, Graves' disease, type 2 diabetes mellitus, mitral valve prolapse, and Gilbert's disease presented with a one month history of jaundice, fatigue, and black stools.[casesjournal.biomedcentral.com]
Muscle Weakness
  • On neurological examination the patient was presented with muscle weakness, muscle atrophy (in face and sternocleidomastoid muscles), features of myotonia and apocamnosis (orbicular muscles).[ncbi.nlm.nih.gov]
  • This case emphasises the importance of considering TPP in patients with acute muscle weakness and the importance of promptly initiating treatment and preventing relapse of TPP.[ncbi.nlm.nih.gov]
  • Graves' disease Other names Toxic diffuse goiter, Flajani–Basedow–Graves disease The classic finding of exophthalmos and lid retraction in Graves' disease Specialty Endocrinology Symptoms Enlarged thyroid, irritability, muscle weakness, sleeping problems[en.wikipedia.org]
  • However, in the longer term, less desirable symptoms, such as muscle weakness, insomnia and trembling can also result. The pulse will likely increase, along with an inability to tolerate heat and abnormally high sweating.[thyroid-info.com]
  • weakness and myopathy • Increased DTR • Increased motor activity • Fatigue Cardiovascular • Tachycardia • Palpitations • Repiratory muscle weakness • Increased RR and HR • Low blood pressure • Heart failure Integumentary • Chronic periarthritis • Dilated[physio-pedia.com]
Diplopia
  • Surgery may also be necessary to correct diplopia when this problem has not improved either spontaneously or with prism lenses.[columbiasurgery.org]
  • Bloodshot appearance to eyes Double vision (diplopia) Impaired vision Treatments for Dry Eyes in Graves’ Disease Your clear choice is TheraLife Autoimmune .[theralife.com]
  • These are: lid fissure width, range of extraocular motion, diplopia fields, and volume of retrobulbar muscle and connective tissue.[doi.org]
  • Patients suffering from Graves' disease may have the following complaints on history: Weight loss Blurred vision, diplopia, photophobia Retro-orbital discomfort and painful eye movements Reduced visual acuity Amenorrhea in females; and erectile dysfunction[symptoma.com]
Red Eye
  • Less severe—but still bothersome—eye symptoms include red eye, tearing, a feeling of sand or dust in the eye(s), and sensitivity to light. Eye disease related to Graves’ disease is called Graves ’ ophthalmopathy .[endocrineweb.com]
Bilateral Proptosis
  • At presentation, he was noted to have bilateral proptosis. Abnormal thyroid function studies and an elevated thyroid-stimulating hormone receptor antibody level confirmed the diagnosis of Graves thyrotoxicosis.[ncbi.nlm.nih.gov]
  • Orbital manifestations of IgG4-rd may include unilateral or bilateral proptosis, cicatricial extraocular muscle myopathy, orbital inflammation and pain which may mimic ophthalmic Graves' disease.[ncbi.nlm.nih.gov]
Infrequent Blinking
  • Note her thyrotoxic stare (infrequent blinking with exophthalmos) and enlarged thyroid gland (goiter). Neonate with thyrotoxicosis secondary to transplacental passage of maternal thyroid-stimulating immunoglobulins (TSI).[emedicine.com]
Increased Sweating
  • The symptoms seen in Graves’ disease include protuberance of eyes, heat intolerance, muscular weakness, increased sweating and anxiety. It most commonly occurs in young individuals. There is no definitive prevention to this disease.[symptoma.com]
  • sweating Rapid pulse felt as palpitations of the heart Fine tremor of the fingers Weakness Miscarriage of a pregnancy if uncontrolled Increased bowel movements and sometimes diarrhea Increased appetite, but weight loss because of the increased metabolism[dummies.com]
  • Graves disease patients may present with heat intolerance, increased sweating, insomnia, frequent loose stools, fatigue, dysmenorrhea, arrhythmia, tremor, weight loss, and neuropsychological symptoms, such as anxiety.[clinicaladvisor.com]
  • These include nervousness or anxiety, extreme tiredness (fatigue), a rapid and irregular heartbeat, hand tremors, frequent bowel movements or diarrhea, increased sweating and difficulty tolerating hot conditions, trouble sleeping, and weight loss in spite[ghr.nlm.nih.gov]
Alopecia
  • Patches of complete hair loss indicate associated alopecia areata. Loss of secondary sexual hair may occur in gonadotropin deficiency. Pretibial myxoedema may occur with any auto-immune thyroid disease.[endobible.com]
  • […] present Diplopia – double vision caused by weakened ocular muscles from long periods of inflammation Photophobia Pretibial myxedema – “orange peel”, thickened, erythematous, lumpy and painless skin, usually found along the shins Fine and brittled hair Alopecia[ihealthblogger.com]
  • Other autoimmune disorders can be associated with Graves disease, including type 1 diabetes mellitus, Addison disease, vitiligo, alopecia, and lupus.[emedicine.com]
  • Hair thinning or diffuse alopecia. Urticaria, pruritus. Brisk reflexes. Goitre. Proximal myopathy (muscle weakness wasting). Gynaecomastia. Lid lag (may be present in any cause of hyperthyroidism).[patient.info]
Pruritus
  • Abstract A 39-year-old multigravida woman presented 3 weeks postpartum with worsening generalised pruritus without primary rash. Workup was significant for cholestasis and undiagnosed Graves' disease.[ncbi.nlm.nih.gov]
  • Abstract A 54-year-old woman suffering from pruritus for five years was diagnosed to have Graves' disease and immune thrombocytopenia (ITP) associated with primary biliary cirrhosis (PBC)-autoimmune hepatitis (AIH) overlap syndrome, which was confirmed[ncbi.nlm.nih.gov]
  • Darkening of the skin may occur, most noticeably in darker-skinned individuals, and intense pruritus may also occur. The skin is typically very fine and moist. Sweating is increased.[emedicine.com]
  • Urticaria, pruritus. Brisk reflexes. Goitre. Proximal myopathy (muscle weakness wasting). Gynaecomastia. Lid lag (may be present in any cause of hyperthyroidism).[patient.info]
Urticaria
  • Urticaria, pruritus. Brisk reflexes. Goitre. Proximal myopathy (muscle weakness wasting). Gynaecomastia. Lid lag (may be present in any cause of hyperthyroidism).[patient.info]
Psychiatric Manifestation
  • The hyperthyroidism that develops is one of many somatic and psychiatric manifestations of the disease that can affect the quality and length of life.[doi.org]
  • Other symptoms associated with the disease are goitre, ophthalmopathy, and psychiatric manifestations such as mood and anxiety disorders and, sometimes, cognitive dysfunction.[ncbi.nlm.nih.gov]
  • Psychiatric manifestations of Graves' hyperthyroidism: pathophysiology and treatment options. CNS Drugs . 2006. 20(11):897-909. [Medline] . Vogel A, Elberling TV, Hørding M, Dock J, Rasmussen AK, Feldt-Rasmussen U.[emedicine.medscape.com]
Emotional Outbursts
  • outbursts, like crying or yelling Rapid growth rate that slows and may ultimately lead to short stature Mothers who have Graves’ disease may pass certain antibodies to their unborn babies, causing them to develop hyperthyroidism.[stanfordchildrens.org]
Emotional Lability
  • Emotional lability, anxiety, and depression The above list, of course, is not complete. Many people will experience some of the above symptoms, and others that are not mentioned here.[gravesdiseasecure.com]
Amenorrhea
  • The most common presentation is the absence of lactation and amenorrhea. Hypothyroidism rather than hyperthyroidism is the usual expected phenomenon in SS.[ncbi.nlm.nih.gov]
  • Patients suffering from Graves' disease may have the following complaints on history: Weight loss Blurred vision, diplopia, photophobia Retro-orbital discomfort and painful eye movements Reduced visual acuity Amenorrhea in females; and erectile dysfunction[symptoma.com]
  • […] dermopaty, tachycardia with palpitations, heat intolerances, weight loss, increased deep tendon reflexes, weakness and muscle atrophy, increased cardiac output, myasthenia gravis, thin hair, warm moist skin, sensitivity to light, dysphasia, diarrhea, amenorrhea[physio-pedia.com]
Irregular Menstruation
  • menstruation – less frequent and less in amount of blood flow Gynecomastia Impotence Increased heart rate Palpitations – fluttering of the chest Chest pain Difficulty of breathing Hand tremors Muscle cramps Muscle weakness Periodic paralysis Frequent[ihealthblogger.com]
Oligomenorrhea
  • […] adipogenesis, the eyeball is displaced resulting in malfunction of the extraocular muscles as well as the venous drainage Clinical features Features of hyperthyroidism: goiter / enlarged thyroid, muscle weakness, tremors, sweating, heat intolerance, oligomenorrhea[pathologyoutlines.com]
Irritability
  • It can cause irritability, sleeplessness and absence of voluntary muscle movements. Elliot was detected with Graves’ disease in 2008.[healthresearchfunding.org]
  • Graves' disease Other names Toxic diffuse goiter, Flajani–Basedow–Graves disease The classic finding of exophthalmos and lid retraction in Graves' disease Specialty Endocrinology Symptoms Enlarged thyroid, irritability, muscle weakness, sleeping problems[en.wikipedia.org]
  • \ ˈgrāvz- \ Definition of Graves' disease : a common form of hyperthyroidism that is an autoimmune disease characterized by goiter, rapid and irregular heartbeat, weight loss, irritability, anxiety, and often a slight protrusion of the eyeballs First[merriam-webster.com]
  • Eyes can feel irritated and be tearing. Double vision may be present.[ufhealth.org]
  • For people who have this condition it is very irritating and cosmetically difficult to treat. Her results -- with just one failure out of 26 eyes -- makes it very compelling for us to give it a try in our patients.[medpagetoday.com]
Tremor
  • Physical examination shows tachycardia (108 bpm), distal tremors and diffuse goiter. After biochemical confirmation of hyperthyroidism, her levothyroxine dose is reduced and finally interrupted.[ncbi.nlm.nih.gov]
  • The signs and symptoms of Graves' disease include insomnia, tremor, hyperactivity, hyperhidrosis, heat intolerance, weight loss despite increased appetite, diarrhea, frequent defecation, palpitations and muscle weakness.[symptoma.com]
  • One week after the treatment, she presented with severe pain in the anterior neck with radiation to the angle of the jaw associated with fatigue, tremor and odynophagia.[ncbi.nlm.nih.gov]
  • Four years after the second surgery, she had heart palpitations and tremors. Laboratory data revealed hyperthyroidism and positive TRAb.[ncbi.nlm.nih.gov]
  • ’ disease is more prevalent in the Caucasian race affecting more women than men, between the ages of 30 and 60. [2] [3] Graves’ disease accounts for 85% of all cases of hyperthyroidism. [4] Characteristics/Clinical Presentation Goiter, Exophthalmos, tremors[physio-pedia.com]
Insomnia
  • The signs and symptoms of Graves' disease include insomnia, tremor, hyperactivity, hyperhidrosis, heat intolerance, weight loss despite increased appetite, diarrhea, frequent defecation, palpitations and muscle weakness.[symptoma.com]
  • However, in the longer term, less desirable symptoms, such as muscle weakness, insomnia and trembling can also result. The pulse will likely increase, along with an inability to tolerate heat and abnormally high sweating.[thyroid-info.com]
  • Symptoms that can indicate whether you have Graves’ disease are: insomnia and hyperactivity hand tremor hair loss excessive sweating and heat intolerance weight loss despite increased appetite diarrhoea palpitations (heartbeat sensations that feel like[in.optelec.com]
  • Some of the more common symptoms include: Weight loss—despite increased appetite Anxiety, restlessness, tremors, irritability, difficulty sleeping (insomnia) Heat intolerance, sweating Chest pain, palpitations Shortness of breath, difficulty breathing[endocrineweb.com]
Hyperactivity
  • Increased energy (hyperactivity) Fatigue Unexplained weight loss Trouble sleeping Inability to tolerate heat Trouble concentrating in school Diarrhea Fast, pounding heartbeat Bulging eyes Irregular periods Shaking Hyperthyroidism can be treated by taking[cincinnatichildrens.org]
  • […] or a toxic nodule (when just one nodule is hyperactive).[sharecare.com]
  • In Graves', the body's hyperactive immune system produces an antibody that attaches to the TSH receptors on the thyroid gland.[study.com]
  • Prolonged exposure to high levels of thyroid-stimulating hormone (characteristic of hyperthyroidism) can pose serious health problems to a child, including the following: Premature closing of bones in the skull (fontanelles) Intellectual disability Hyperactivity[stanfordchildrens.org]
  • […] type II hypersensitivity anti-microsomal, anti-thyroglobulin antibodies also present Female dominant HLA-B8, Dr3 association Often incited during stress e.g. childbirth, infection, steroid withdrawal Presentation Symptoms heat intolerance weight loss hyperactive[step2.medbullets.com]
Hand Tremor
  • Some symptoms of hyperthyroidism include a racing heart, irritability, nervousness, hand tremors, and weakness of muscles. Other symptoms include: Goiter: This is another name for an enlarged thyroid gland.[my.clevelandclinic.org]
  • Patients with Graves' disease may have some of the common symptoms such as anxiety, difficulty in sleeping, fatigue, muscle weakness, nervousness, hand tremors, frequent bowel movements, increased appetite, rapid and irregular heartbeat, weight loss,[melbournethyroidcentre.com.au]
  • Graves’ disease shares some of the same symptoms as hyperthyroidism, such as: Fatigue or muscle weakness Frequent bowel movements or diarrhea Goiter — an enlarged thyroid that may cause the neck to swell or bulge Hand tremors Heat intolerance Nervousness[mountsinai.org]
  • Symptoms that can indicate whether you have Graves’ disease are: insomnia and hyperactivity hand tremor hair loss excessive sweating and heat intolerance weight loss despite increased appetite diarrhoea palpitations (heartbeat sensations that feel like[in.optelec.com]

Workup

Various tests are helpful in establishing any diagnosis related to the thyroid gland.

  • In Graves’ disease, free T4 and T3 levels are usually elevated. There are certain conditions (such as toxic nodular goiter) in which only T3 levels are elevated. Such conditions are called T3 toxicosis.
  • TSI (thyrotropin receptor anti-bodies) are mostly used as diagnostic test for Graves’ disease. Assays for TSI are mostly positive.
  • Serum antibodies against collagen XIII are high in active Graves’ ophthalmopathy [11].
  • Other markers include antithyroglobulin antibodies and antithyroidal peroxidase antibodies.
Nephrolithiasis
  • Reduction of refractory hypercalciuria If the patient has refractory hypercalciuria (as is mainly seen in pre-existing renal insufficiency or nephrolithiasis), hydrochlorothiazide can be given at a high dose (25 to 10 mg daily).[doi.org]
Abnormal Thyroid Function Test
  • The prevalence of affective disorder and in particular of a rapid cycling of bipolar disorder in patients with abnormal thyroid function test. Clin Endocrinol 1996 Aug; 45(2): 215–23 CrossRef Google Scholar 50. Thomsen AF, Kessing LV.[doi.org]
HLA-B8
  • […] and thyroglobulin, which are also present in Hashimoto’s thyroiditis Epidemiology Affects 2% of women in US, 0.3% of men 85% of patients are women, usually ages 20 - 40 years; men are usually older 60% concordance in identical twins; associated with HLA-B8[web.archive.org]
  • Introduction Most common cause of hyperthyroidism An autoimmune disease with stimulating anti-TSH receptor antibodies a type II hypersensitivity anti-microsomal, anti-thyroglobulin antibodies also present Female dominant HLA-B8, Dr3 association Often[step2.medbullets.com]
  • Most common cause of hyperthyroidism in United States, affecting 2% of women and 0.3% of men 85% of patients are women (female to male ratio is 4:1), usually ages 20 - 40 years; men are usually older 60% concordance in identical twins; associated with HLA-B8[pathologyoutlines.com]
HLA-DR3
  • […] thyroglobulin, which are also present in Hashimoto’s thyroiditis Epidemiology Affects 2% of women in US, 0.3% of men 85% of patients are women, usually ages 20 - 40 years; men are usually older 60% concordance in identical twins; associated with HLA-B8 and HLA-DR3[web.archive.org]
  • […] cause of hyperthyroidism in United States, affecting 2% of women and 0.3% of men 85% of patients are women (female to male ratio is 4:1), usually ages 20 - 40 years; men are usually older 60% concordance in identical twins; associated with HLA-B8 and HLA-DR3[pathologyoutlines.com]

Treatment

The treatment of Graves’ disease depends upon symptoms and thyrotoxic states. Treatment options include drugs, surgery and radiation.

Medication

  • Anti-thyroid drugs such as carbimazole and propylthiouracil interfere with the normal functioning of the thyroid gland.
  • beta-blockers are used to treat the symptoms caused by hyper-functioning of the sympathetic system.

Surgery

Either total or subtotal thyroidectomy is performed to reduce the mass of the active thyroid gland.

Radioactive Iodine

In the United States, radioactive iodine is given as first line therapy. Its dose usually ranges from 5-15 mCi. Thyroid function tests usually show improvement after 6 to 8 weeks of therapy. Radioactive iodine is absolutely contraindicated in pregnancy.

Prognosis

Many patients remain well after a single course of anti-thyroid drugs, but recurrence can happen at any time. Radioactive iodide is very effective, but often results in abnormally low levels of thyroid hormones (hypothyroidism). Surgery can also cause low levels of thyroid hormones.

The eye signs of Graves' disease tend to improve with anti-thyroid drug treatment. However, some element of the staring appearance often remains.

Etiology

Normally thyroid gland releases its hormones (T3 and T4) under actions of thyroid stimulating hormone (TSH) that is produced by the pituitary gland in brain. In Graves' disease, abnormal antibodies are produced that are capable of mimicking the action of thyroid stimulating hormone. As a result, the levels of thyroid hormones T3 and T4 are increased. All these conditions collectively result into condition like Graves’ disease.

Moreover there are various other etiological factors that trigger increased thyroid hormone release such as thyroid surgery, trauma to thyroid gland, thyroid adenoma and thyroid carcinoma.

Epidemiology

The prevalence of Graves’ disease varies in different areas around the world. Graves’ disease is most common cause of hyperthyroidism in the United States. These patients often have a family history of autoimmune diseases involving the thyroid gland which include Hashimoto thyroiditis, postpartum thyroiditis, Riedel thyroiditis and others [1]. Graves' disease is also commonly associated with non-thyroid conditions including diabetes mellitus type 1, myasthenia gravis, pernicious anemia, systemic lupus erythematosus, vitiligo and Sjogren syndrome [2].

The prevalence of maternal thyrotoxicosis is 1 case per 500 persons approximately in United States. In the United Kingdom, the incidence was reported to be 80 cases 100,000 per year in women [3].

Worldwide, Graves’ disease represents 60 to 90% of all causes of thyrotoxicosis. In one study, the incidence was reported to be around 100 to 200 cases per 100,000 population annually.

Sex distribution
Age distribution

Pathophysiology

The hormones released by thyroid gland regulate the body metabolism and control the rate at which food is converted into energy form. The rate of metabolism is directly dependent on the amount of thyroid hormones released. If for some reason, there is an excessive production of hormones, the body metabolism is enhanced to very higher levels producing symptoms like sweating, trembling, weight loss in hyperthyroid individuals.

Graves’ disease is an autoimmune disorder mediated by autoantibodies that are capable of binding and stimulating the receptor for thyroid stimulating hormone on the thyroid gland [4]. Continued stimulation of the thyroid gland results in hypertrophy of the gland and overproduction of its hormones.

Binding of these antibodies to similar antigen retro-orbital connective tissue causes the ocular symptoms of Graves' disease.

Prevention

There is no way to prevent Graves' disease as it is genetically mediated.

Summary

Graves’ disease is an autoimmune disorder characterized by hyperthyroidism due to circulating autoantibodies that are capable of stimulating the thyroid gland. It most commonly results in increased thyroid gland (twice or more of its size) due to increased synthesis of thyroid hormones by hyperfunctioning thyroid follicles.

Patient Information

Graves’ disease is a disorder in which the thyroid gland becomes overactive because bof stimulation by the body’s own antibodies. The symptoms seen in Graves’ disease include protuberance of eyes, heat intolerance, muscular weakness, increased sweating and anxiety.

It most commonly occurs in young individuals. There is no definitive prevention to this disease. Treatment can be done through drugs, surgery or radiation with favorable results.

References

Article

  1. Boelaert K, Newby PR, Simmonds MJ, et al. Prevalence and relative risk of other autoimmune diseases in subjects with autoimmune thyroid disease. The American journal of medicine. Feb 2010;123(2):183 e181-189.
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Last updated: 2018-06-22 10:14