Graves Disease

GRAVES DISEASE

The hyperthyroidism of Graves’ disease is the result of circulating IgG antibodies that bind to and activate the G-protein–coupled thyrotropin receptor.This activation stimulates follicular hypertrophy and hyperplasia, causing thyroid enlargement, as well as increases in thyroid hormone production and the fraction of triiodothyronine (T3) relative to thyroxine (T4) in thyroid secretion (from approximately 20% to as high as 30%). Thyroid-function testing in Graves’ disease typically reveals a suppressed serum thyrotropin level and elevated levels of serum T4 and T3. A suppressed serum thyrotropin level with normal serum levels of T4 and T3 is referred to as subclinical hyperthyroidism. Graves’ ophthalmopathy is clinically apparent in approximately 30 to 50% of patients with Graves’ disease, but it is detected in more than 80% of patients who undergo assessment by means of orbital imaging. Manifestations of ophthalmopathy, which vary in severity and have a course that is typically independent of the thyroid disease, can include proptosis, periorbital edema and inflammation, exposure keratitis, photophobia, extraocular muscle infiltration, and eyelid lag - Von graeffe sign (which can also occur with augmented adrenergic stimulation).

Panel A shows a man with bilateral exophthalmos and marked retraction of the upper eyelid. Panel B shows a woman with mild inflammatory signs and hypotropia in the right eye. Panel C shows a woman with marked edema and redness in the upper eyelid, redness of the conjunctiva, and severe chemosis in the left eye. Panel D shows a man with marked edema and retraction of the eyelid and exophthalmos. Panel E shows a woman with marked redness of the conjunctiva and chemosis. There is marked impairment of movement of the globes, which are unable to follow the examiner's finger; this patient had severe dysthyroid optic neuropathy, which responded dramatically to intravenous glucocorticoids (Cortesy of NEJM)

Clinical manifestations

Semiology Apart


This patient has a lot of graves signs: first et all, a big difuse goiter, probably exophtalmos, eyelid lag ( Von graeffe Sign), Pemberton sign ( yugular ingurgitation when rise up her arms due obstruction) and binocular vision impairment (Moebius sign).

The female-to-male ratio among patients with Graves’ disease is between 5:1 and 10:1. The peak incidence is between 40 and 60 years of age, although the disease can occur at any age.

Tests for Graves’ disease–associated antibodies are useful in the evaluation of some conditions, but they are not usually required for diagnosis or to monitor disease activity

IMAGING

A radioiodine-uptake study should be performed in patients in whom painless thyroiditis is considered to be a diagnostic possibility and in patients with an irregular or nodular thyroid gland.

CT is not needed for ophtalmopathy for primary care, and EKG should be performed.

THERAPY

The treatment options for Graves’ disease include antithyroid drugs (propylthiouracil and methimazole), radioiodine, and surgery.

References

- Graves DIsease Review - NEJM