Autoimmune hyperthyroid disorder that classically comprises hyperthyroidism with a diffuse goitre, eye disease characterized by inflammation and involvement of intra-orbital structures, dermopathy to as pretibial myxoedema, and rare involvement of the nails, fingers and long bones known as acropachy.
Graves’ disease is an autoimmune disorder that results in the overproduction of thyroid hormones. It is the most common cause of hyperthyroidism. Women 20 to 40 years of age are typically affected. Thyrotoxicosis may cause unexplained weight loss due to an increased metabolic rate. Patients may present with goiter, exophthalmos, diaphoresis, tremors, heat intolerance, loose stools, and pretibial myxedema. The most common cardiac manifestation is tachycardia, often associated with palpitations. The treatment options for Graves’ disease include antithyroid drugs, radioiodine therapy, and thyroidectomy. | Graves’ Disease: Jorge Muniz, PA-C
Contents
Autoimmune hyperthyroid disorder that classically comprises hyperthyroidism with a diffuse goitre, eye disease characterized by inflammation and involvement of intra-orbital structures, dermopathy to as pretibial myxoedema, and rare involvement of the nails, fingers and long bones known as acropachy.
M/C cause of hyperthyroidism (60-80% cases)
History:
Robert James Graves, F.R.C.S. (1796 – 1853) was an eminent Irish surgeon after whom Graves’ disease takes its name. He was President of the Royal College of Physicians of Ireland, Fellow of the Royal Society of London and the co-founder of the Dublin Journal of Medical Science. He is also the uncredited inventor of the second-hand on watches.
Originally known as ‘exophthalmic goitre’, Graves’ disease owes its name to the Irish physician, Robert James Graves, who described the condition in 1835. Graves’ disease is a syndrome that classically comprises hyperthyroidism with a diffuse goitre, eye disease characterized by inflammation and involvement of intra-orbital structures, dermopathy referred to as pretibial myxoedema, and rare involvement of the nails, fingers and long bones known as acropachy. Prior to its description by Graves, others including the Greek philosopher Aristotle and the English physician Caleb Parry had noted unique aspects of the condition.
Etiology
Risk factors:
Genetic susceptibility
Stress
Smoking (esp associated with ophthalmopathy)
Female sex (sex steroids)
Post-partum period
Iodine (incl. amiodarone)
Lithium
Associated conditions:
Autoimmune conditions:
Diabetes mellitus type 1
Pernicious anaemia
Celiac disease
Vitiligo
Addison disease
Alopecia areata
Myasthenia gravis
Other conditions:
Hypokalemic periodic paralysis (particularly in Asian males)
Caused by thyroid-stimulating immunoglobulin (TSI), also known as thyroid-stimulating antibody (TSAb)
The Calgary Guide | http://calgaryguide.ucalgary.ca/
Graves dermopathy:
Pretibial myxedema (thyroid dermopathy)
Thyroid acropachy (clubbing of fingers & toes + soft-tissue swelling of hands & feet)
Patchy vitiligo (some)
Pretibial myxedema and thyroid acropachy accompanying hyperthyroidism – This 33-year-old woman presented with painless swelling of her fingers and lower legs of about four months’ duration. | Herbert L. Fred, MD and Hendrik A. van Dijk – http://cnx.org/content/m14924/latest/, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=5038257Bilateral erythematous infiltrative plaques on lower extremities in 42-year-old man with Graves disease are consistent with pretibial myxedema. Myxedematous changes of skin usually occur in pretibial areas and resemble orange peel in color and texture. | Pr. (2020) What are the dermatologic manifestations of Graves disease?. Retrieved January 30, 2020, from https://www.medscape.com/answers/121865-25225/what-are-the-dermatologic-manifestations-of-graves-disease
Graves’ orbitopathy (ophthalmopathy):
Caused by inflammation, cellular proliferation and increased growth of extraocular muscles and retro-orbital connective and adipose tissues due to the actions of thyroid stimulating antibodies and cytokines released by cytotoxic T lymphocytes (killer cells).
Classic severe Graves’ ophthalmopathy demonstrating a widened palpebral fissure, periorbital edema, proptosis, chemosis, and conjunctival injection. | DeGroot LJ. Graves’ Disease and the Manifestations of Thyrotoxicosis. [Updated 2015 Jul 11]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK285567/Severe proptosis, periorbital edema, and eyelid retraction from thyroid-related orbitopathy. This patient also had optic nerve dysfunction and chemosis (conjunctival edema) from thyroid-related orbitopathy. | Pr. (2020) What are the dermatologic manifestations of Graves disease?. Retrieved January 30, 2020, from https://www.medscape.com/answers/121865-25225/what-are-the-dermatologic-manifestations-of-graves-disease
Complications
Congestive heart failure:
Differences between hyperthyroid and nonhyperthyroid heart failure. | Osuna, P. M., Udovcic, M., & Sharma, M. D. (2017). Hyperthyroidism and the Heart. Methodist DeBakey cardiovascular journal, 13(2), 60–63. doi:10.14797/mdcj-13-2-60
Osteoporosis
Thyroid storm:
Most commonly seen in the context of underlying Graves’ hyperthyroidism but can complicate thyrotoxicosis of any aetiology.
Occurs when hyperthyroid patient stops treatment/develops infection/has surgery
Clinical features represent manifestations of organ decompensation, with fever seen almost universally.
Causes of death in Japanese patients with TS. CHF, congestive heart failure; DIC, disseminated intravascular coagulation; GI, gastrointestinal; MOF, multiple organ failure. | Akamizu T. (2018). Thyroid Storm: A Japanese Perspective. Thyroid : official journal of the American Thyroid Association, 28(1), 32–40. doi:10.1089/thy.2017.0243
Management
Treatment for Grave’s disease | Ginsberg, J. (2003). Diagnosis and management of Graves’ disease. Canadian Medical Association Journal, [online] 168(5), pp.575-585. Available at: http://www.cmaj.ca/content/168/5/575.full [Accessed 24 May 2017]
Treatment algorithm for Graves’ disease. | Girgis, C. M., Champion, B. L., & Wall, J. R. (2011). Current concepts in graves’ disease. Therapeutic advances in endocrinology and metabolism, 2(3), 135–144. doi:10.1177/2042018811408488
Prognosis
Factors associated with either a higher likelihood of immunological remission following a course of ATDs or with increased resistance to RAI | Ginsberg, J. (2003). Diagnosis and management of Graves’ disease. Canadian Medical Association Journal, [online] 168(5), pp.575-585. Available at: http://www.cmaj.ca/content/168/5/575.full [Accessed 24 May 2017]
