Graves disease is the most common cause of hyperthyroidism in countries with sufficient iodine intake.
Caused by TSH receptor antibodies.
Extrathyroidal manifestations include orbitopathy, pretibial myxedema (thyroid dermopathy), or acropachy, which do not occur with other causes of hyperthyroidism.
Diagnostic tests are suppressed serum TSH, elevated levels of circulating thyroid hormones, detectable TSH receptor antibodies, and high thyroid uptake of radioactive iodine (or technetium 99).
Treatment options are antithyroid drugs, radioactive iodine therapy, and thyroid surgery.
Untreated hyperthyroidism, particularly in older people, may result in cardiac arrhythmias, high-output cardiac failure, bone mineral loss, and rarely thyroid storm.
Unusual complications include vision loss secondary to orbitopathy or elephantiasis secondary to dermopathy.
Graves disease is an autoimmune thyroid condition associated with hyperthyroidism. Associated orbitopathy occurs in around 25% of cases and is usually mild; associated dermopathy and acropachy are rare, and almost always seen with orbitopathy. TSH (thyroid-stimulating hormone) receptor antibodies cause the hyperthyroid syndrome and underlie the extrathyroidal manifestations. Diagnosis is mostly clinical and is usually confirmed by laboratory evidence of thyroid dysfunction, most commonly hyperthyroidism.
History and exam
Key diagnostic factors
- family history of autoimmune thyroid disease
- history of tobacco use
- heat intolerance
- weight loss
- diffuse goiter
Other diagnostic factors
- cardiac flow murmur
- moist, velvety skin
- scalp hair loss
- sexual dysfunction
- muscle weakness
- thyroid bruit
- pretibial myxedema
- menstrual irregularity
- family history autoimmune thyroid disease
- female gender
- tobacco use
- high iodine intake
- lithium therapy
- biologic agent and cytokine therapies
- radioiodine therapy for benign nodular goiter
1st investigations to order
- TSH receptor antibodies (TRAb)
- serum free or total T4
- serum free or total T3
Investigations to consider
- calculation of total T3/T4 or FT3/FT4 ratio
- radioactive iodine (I-131 or I-123) or technetium-99 (Tc-99) uptake
- thyroid isotope scan
- thyroid peroxidase antibodies (TPOAb)
- thyroid ultrasound
- CT or MRI scan of orbit
- skin biopsy
subclinical Graves disease
symptomatic nonpregnant, nonlactating adults
- Toxic nodular goiter
- Painless and postpartum thyroiditis
- Gestational hyperthyroidism
- Management of pediatric Graves' disease
- Guidelines for the medical management of Graves' orbitopathy
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