Graves disease
Updates to Article Attributes
Graves disease (also known as Basedow disease inmainland Europe9) is an autoimmune thyroid disease and is the most common cause of thyrotoxicosis (up to 85%).
Epidemiology
There is a strong female predilection with an F:M ratio of at least 5:1. It typically presents in middle age.
Clinical presentation
Patients are thyrotoxic. Extrathyroidal manifestations include:
- cutaneous manifestations of Graves disease
- thyroid dermopathy (formerly called pretibial myxoedema): occurs in ~2% and almost always associated with thyroid ophthalmopathy 7
- skeletal manifestations of Graves disease
- thyroid acropachy: occurs in ~1% 7
- Graves ophthalmopathy (orbitopathy): affects 20-25% of cases
-
encephalopathy associated with autoimmune thyroid disease (EAATD) 2,8
- much more commonly associated with Hashimoto thyroiditis
The combination of exophthalmos, palpitations, and goitre is called the Merseburger (or MersebergMerseburg) triad.
Pathology
Results from an antibody directed stimulation of the thyroid-stimulating hormone (TSH) receptor, with resultant production and release of T3 and T4.
Macroscopic appearance
The affected gland shows diffuse, symmetrical enlargement, with a fleshy red cut surface. This appearance can be altered by preoperative treatment or chronicity.
Microscopic appearance
The histological features are consistent with the activated state of the gland:
- plump follicular cells with increased amounts of eosinophilic cytoplasm
- hyperplastic follicles with papillary epithelial infoldings
- evidence of colloid reabsorption including 'scalloping' at the apical membrane and variable follicle collapse and exhaustion
These features can be altered by preoperative treatment or chronicity.
Serology
- TSH: suppressed
- T4: elevated
- T3: elevated
- TSH receptor antibodies (TSI, TGI, TBII): positive
Radiographic features
Ultrasound
- thyroid gland is often enlarged and can be hyperechoic
- heterogeneous thyroid echotexture
- relative absence of nodularity in uncomplicated cases
- hypervascular; may demonstrate a thyroid inferno pattern on colour Doppler 1
Nuclear medicine
- iodine-123: imaging performed at around 2-6 days; classically demonstrates homogeneously increased activity in an enlarged gland
- technetium-99m pertechnetate: homogeneously increased activity in an enlarged thyroid gland
History and etymology
It is named after Robert James Graves (1796-1852),Irish surgeon, who first described it in 1835 9, and Carl Adolph von Basedow (1799-1854), German physician, who described it in 1840 10,11,13. The Merseburger triad was first described by Basedow who practiced in Merseburg 12,13.
Differential diagnosis
For hyperthyroidism consider:
- Marine-Lenhart syndrome
- toxic thyroid adenoma
- toxic multinodular goitre
- inflammatory:
- pituitary adenoma
- extrathyroid origin
- struma ovarii
- metastatic thyroid carcinoma
- factitious hyperthyroidism
Practical points
- patients with Graves disease are at higher risk of iodinated contrast media-induced thyrotoxicosis
-<a title="thyroid dermopathy" href="/articles/thyroid-dermopathy">thyroid dermopathy</a> (formerly called pretibial myxoedema): occurs in ~2% and almost always associated with thyroid ophthalmopathy <sup>7</sup>- +<a href="/articles/thyroid-dermopathy">thyroid dermopathy</a> (formerly called pretibial myxoedema): occurs in ~2% and almost always associated with thyroid ophthalmopathy <sup>7</sup>
-<a title="Steroid responsive encephalopathy associated with autoimmune thyroiditis" href="/articles/steroid-responsive-encephalopathy-associated-with-autoimmune-thyroiditis-1">encephalopathy associated with autoimmune thyroid disease (EAATD)</a> <sup>2,8</sup><ul><li>-<a title="Steroid responsive encephalopathy associated with autoimmune thyroiditis" href="/articles/steroid-responsive-encephalopathy-associated-with-autoimmune-thyroiditis-1"></a>much more commonly associated with <a title="Hashimoto thyroiditis" href="/articles/hashimoto-thyroiditis">Hashimoto thyroiditis</a>- +<a href="/articles/steroid-responsive-encephalopathy-associated-with-autoimmune-thyroiditis-1">encephalopathy associated with autoimmune thyroid disease (EAATD)</a> <sup>2,8</sup><ul><li>
- +<a href="/articles/steroid-responsive-encephalopathy-associated-with-autoimmune-thyroiditis-1"></a>much more commonly associated with <a href="/articles/hashimoto-thyroiditis">Hashimoto thyroiditis</a>
-</ul><p>The combination of exophthalmos, palpitations, and goitre is called the Merseburger (or Merseberg) triad.</p><h4>Pathology</h4><p>Results from an antibody directed stimulation of the thyroid-stimulating hormone (TSH) receptor, with resultant production and release of T3 and T4.</p><h5>Macroscopic appearance</h5><p>The affected gland shows diffuse, symmetrical enlargement, with a fleshy red cut surface. This appearance can be altered by preoperative treatment or chronicity.</p><h5>Microscopic appearance</h5><p>The histological features are consistent with the activated state of the gland:</p><ul>- +</ul><p>The combination of exophthalmos, palpitations, and goitre is called the Merseburger (or Merseburg) triad.</p><h4>Pathology</h4><p>Results from an antibody directed stimulation of the thyroid-stimulating hormone (TSH) receptor, with resultant production and release of T3 and T4.</p><h5>Macroscopic appearance</h5><p>The affected gland shows diffuse, symmetrical enlargement, with a fleshy red cut surface. This appearance can be altered by preoperative treatment or chronicity.</p><h5>Microscopic appearance</h5><p>The histological features are consistent with the activated state of the gland:</p><ul>
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