Diagnosis

Graves disease

Autoimmune disorder resulting in hyperthyroidism which can cause systemic manifestations that primarily affect heart, skeletal muscle, eyes, skin, bone, and liver.

Also known as: Autoimmune hyperthyroidism, Basedow's disease, Graves-Basedow disease, Toxic diffuse goiter

Etiology

Cause/Pathophysiology [wc1]

  1. Susceptible genes triggered --> autoimmune disorder

  2. Immunoglobulins binding TSH-reseptors

  3. Stimulating excess production of thyroid hormone and thyroid gland growth

    • Increased metabolic rate:

      Tachycardia, systolic hypertension, sweating, heat intolerance, tremors, lid lag, fatigue, weight loss, atrial fibrillation, palpitation, hyper defecation, insomnia, anxiety, nervousness, hyperkinesia, hyperreflexia, dyspnea, muscle weakness, pruritus, polyuria, oligomenorrhea or amenorrhea, loss of libido, palmar erythema and onycholysis, hair loss

    • Ophthalmopathy is caused by inflammation, cellular proliferation and excess of retro-orbital connective and adipose tissues

    • Pretibial myxedema

    • Thyroid acropachy

Risk factors [wc1]

Complications [wc1]

Epidemiology

Incidence per 100.000 [gef][ccn][icd][7qp][wc1]

Epidemiology chart for Incidence

Symptoms & findings

Symptoms

Alopecia, Amenorrhea, Anxiety, Change in bowel habits, Decreased libido, Diaphoresis, Diplopia, Dyspnea, Exophthalmos, Fatigue, Heat intolerance, Impotence, Increased appetite, Infertility, Insomnia, Irritability, Myxedema, Nail clubbing, Night sweats, Oligomenorrhea, Onycholysis, Palpitations, Photophobia, Polydipsia, Polyuria, Restlessness, Tachycardia, Tremor, Vascular murmur, Weakness, Weight loss, Wide pulse pressure

Clinical findings

Anemia, Decreased HDL, Decreased TSH, Elevated ALAT, Elevated ALP, Elevated ASAT, Elevated Bilirubin, Elevated T3, Elevated T4, Gynecomastia, Hypercalcemia, Increased iodide uptake, Thrombocytopenia

Anamneses

None listed.

Localized findings

Rash
Radiates
Hand
Distribution
Symmetric
Lesion type
Erythema
Color
Red
Palpation
Blanching
Swelling
Radiates
Collum
Onset
Gradual (days)
Pattern
Constant

Approach

Treatment

Treatment goal: rapid symptoms control and reduction of thyroid hormone secretion [wc1]

  1. Tachycardia >90/min: Beta blocker and/or calcium channel blockers

  2. Ophthalmopathy: Correction of thyroid hormone + prednisone/Rituximab

  3. Reduce thyroid hormone synthesis:

    1. Antithyroid drugs which block thyroid hormone synthesis:

      • Methimazole (nonpregnant patients)

      • Propylthiouracil (1st trimester)

    2. Radioactive iodine treatment of the thyroid gland

    3. Total or subtotal thyroidectomy

      • Large goiter

      • Neck compressive symptoms

      • Suspicious thyroid cancer

      • Large thyroid nodules

      • Cold nodules

      • Co-existing parathyroid adenoma

      • High TRAb

      • Graves orbitopathy

Differential diagnoses

Acute thyroiditis, Anxiety, Cocaine toxicity, Hashimotos thyroiditis, Pheochromocytoma, Pituitary adenoma, Postpartum thyroiditis, Struma ovarii, Subacute thyroiditis, Thyroid cancer, Toxic nodular goiter, Toxic thyroid adenoma, Wolff-Parkinson-White Syndrome

References

[1] Pokhrel B, Bhusal K. Graves Disease. [Updated 2023 Jun 20]: https://www.ncbi.nlm.nih.gov/books/NBK448195/

[2] Andersen SL, Laurberg P. Managing hyperthyroidism in pregnancy: current perspectives. Int J Womens Health. 2016 Sep 19;8:497-504.

[3] Berglund J, Christensen SB, Hallengren B. Total and age-specific incidence of Graves' thyrotoxicosis, toxic nodular goitre and solitary toxic adenoma in Malmö 1970-74. J Intern Med. 1990 Feb;227(2):137-41.

[4] Williamson S, Greene SA. Incidence of thyrotoxicosis in childhood: a national population based study in the UK and Ireland. Clin Endocrinol (Oxf). 2010 Mar;72(3):358-63.

[5] Havgaard Kjær R, Smedegård Andersen M, Hansen D. Increasing Incidence of Juvenile Thyrotoxicosis in Denmark: A Nationwide Study, 1998-2012. Horm Res Paediatr. 2015;84(2):102-7.

[6] http://emedicine.medscape.com/article/120619 (2014-01-02); [Medscape]

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