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
Salman Razvi, MD
Consultant Endocrinologist and Senior Lecturer
Translational and Clinical Research Institute, Queen Elizabeth Hospital, Gateshead
Newcastle upon Tyne
SR has received speaker fees from Merck plc and Abbott India Pharmaceuticals Ltd, the makers of levothyroxine.
Dr Salman Razvi would like to gratefully acknowledge Dr Petros Perros, Dr Douglas S. Ross, Dr George Hennemann, and Dr Vahab Fatourechi, previous contributors to this topic.
PP, DSR, GH, and VF are authors of references cited in this topic.
Elizabeth N. Pearce, MD
Associate Professor of Medicine
Boston University Medical Center
ENP is a consultant for Scientific Consulting Company GmbH and a management council member for the Iodine Global Network.
Kristien Boelaert, MD, PhD, FRCP
Reader in Endocrinology
Institute of Metabolism and Systems Research
College of Medical and Dental Sciences
University of Birmingham
KB declares that she has no competing interests.
Paul Carroll, MD, FRCP
Clinical Lead for Endocrinology
Chair of Thyroid MDM
Guy’s and St Thomas’ NHS Trust
PC declares that he has no competing interests.
David Cooper, MD
Sinai Hospital of Baltimore
DC declares that he has no competing interests.
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