Grave’s Disease

Introduction 

Grave’s disease is an autoimmune thyroid disorder characterized

by circulating antibodies that stimulate the TSH receptor, resulting in the increase in synthesis and release of thyroid hormones 

-it is the most common cause of hyperthyroidism and thyrotoxicosis 

-It is more common in women than in men with onset usually between 20 and 40 years of age 

-Dietary iodine supplementation can trigger Graves disease

-Thyrotoxicosis: clinical state resulting from inappropriately high thyroid hormone levels

hyperthyroidism: thyrotoxicosis caused by elevated synthesis and secretion of thyroid hormone

Symptoms & Signs

General: fatigue, fever, heat intolerance, weight change, irritability, intolerance    

Thyroid: diffusely enlarged thyroid often with a loud bruit 

Eyes: infiltrative ophthalmopathy (Graves exophthalmos),spasm of the upper eyelid revealing the sclera above the corneoscleral limbus (Dalrymple’s sign) , lid lag with downward gaze (von Graefe sign), a staring appearance (Kocher sign), conjunctival swelling and congestion, keratitis, papilledema, permanent visual loss 

Nervous: Restlessness, nervousness, fine resting tremors 

Cardiac: palpitations, angina,exertional dyspnea, atrial fibrillation, premature atrial contractions, atrial tachycardia, ischemic or valvular heart disease, pulmonary hypertension    

Gastrointestinal: dysphagia, frequent bowel movements, diarrhea  

Musculoskeletal: muscle weakness, cramps, osteoporosis  

Dermatologic: facial flushing, moist warm skin, pruritis, increased sweating, fine hair, onycholysis,bony involvement leads to subperiosteal bone formation and swelling in the metacarpals (thyroid acropachy), infiltrative dermopathy (pretibial myxedema)

Genitourinary: menstrual irregularities  amenorrhea, decreased fertility, and an increased incidence of miscarriages

Diagnosis 

Serum TSH: low or undetectable 

free T4 or T3: elevated 

Thyroid receptor antibodies (TRAbs): elevated 

RAI scan: elevated uptake and a homogeneous pattern 

Technetium scintigraphy: increased or normal thyroid uptake of technetium 

Treatment 

Symptomatic treatment: beta blockers, calcium blockers 

Antithyroid drugs: Methimazole, carbimazole, propylthiouracil 

Radioactive iodine (131I, RAI): the most commonly prescribed treatment in the United States, but is contraindicated in pregnancy or with breastfeeding 

surgery: a total resection of one lobe and a subtotal resection of the other lobe

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