Graves disease

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Graves disease is an autoimmune thyroid disease and is the ~~commonest~~most common cause of thyrotoxicosis (up to 85%).

Epidemiology

There a strong female predilection with the F:M ratio of at least 5:1. Typically presents in middle age.

Clinical presentation

Patients are thyrotoxic

~~Extra thyroid~~. Extra-thyroid manifestations include:

cutaneous manifestations of Graves disease
- pretibial myxoedema (thyroid dermopathy): occurs in ~2% and almost associated with thyroid ophthalmopathy ⁷
skeletal manifestations of Graves disease
- thyroid acropachy: occurs in ~1% ⁷
Graves ophthalmopathy or orbitopathy: affects ~~~20~~20-25 % of cases
encephalopathy associated with autoimmune thyroid disease (EAATD) ^{2, 8}

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 ~~effected~~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
thyroid ~~recepter~~receptor antibodies (TSI, TGI, TBII): positive

Radiographic features

Ultrasound

~~the~~ thyroid gland is often enlarged and can be hyperechoic
~~the is a~~ relative absence of nodularity in uncomplicated cases
~~hyper vascular and may~~hypervascular; may demonstrate a "thyroid inferno" pattern on colour Doppler ¹

ScintigraphyNuclear medicine

I ¹²³: imaging performed at around 2-6 days~~. classically~~; classically demonstrates homogeneously increased activity in an enlarged gland
Tc ⁹⁹Pertechnetate: homogeneously increased activity in an enlarged thyroid gland

Differential diagnoses fordiagnosis

For hyperthyroidism consider:

Marine-Lenhart syndrome
toxic thyroid adenoma
toxic multinodular goiter
inflammatory:
- subacute thyroiditis
- postpartum thyroiditis
- silent thyroiditis
pituitary adenoma
extrathyroid origin
Struma ovarii
metastatic thyroid carcinoma
factitious hyperthyroidism

History and etymology

It is named after Robert James Graves: ,Irish Surgeon (1796-1853).

Practical points

patients with Graves disease are at higher risk of iodinated contrast-induced thyrotoxicosis

-<p><strong>Graves disease</strong> is an <a href="/articles/autoimmune-thyroid-disease">autoimmune thyroid disease</a> and is the commonest cause of <a href="/articles/thyrotoxicosis">thyrotoxicosis </a>(up to 85%).</p><h4>Epidemiology</h4><p>There a strong female predilection with the F:M ratio of at least 5:1. Typically presents in middle age.</p><h4>Clinical presentation</h4><p>Patients are thyrotoxic</p><p>Extra thyroid manifestations include:</p><ul>
~~-<li><a href="/articles/cutaneous-manifestations-of-graves-disease">cutaneous manifestations of Graves disease</a></li>~~
~~-<li><a href="/articles/skeletal-manifestations-of-graves-disease">skeletal manifestations of Graves disease</a></li>~~
+<p><strong>Graves disease</strong> is an <a href="/articles/autoimmune-thyroid-disease">autoimmune thyroid disease</a> and is the most common cause of <a href="/articles/thyrotoxicosis">thyrotoxicosis </a>(up to 85%).</p><h4>Epidemiology</h4><p>There a strong female predilection with the F:M ratio of at least 5:1. Typically presents in middle age.</p><h4>Clinical presentation</h4><p>Patients are thyrotoxic. Extra-thyroid manifestations include:</p><ul>
+<li>cutaneous manifestations of Graves disease<ul><li>
+<a title="pretibial myxoedema" href="/articles/pretibial-myxoedema">pretibial myxoedema</a> (thyroid dermopathy): occurs in ~2% and almost associated with thyroid ophthalmopathy <sup>7</sup>
+</li></ul>
+</li>
+<li>skeletal manifestations of Graves disease<ul><li>
+<a title="Thyroid acropachy" href="/articles/thyroid-acropachy">thyroid acropachy</a>: occurs in ~1% <sup>7</sup>
+</li></ul>
+</li>
~~-<a href="/articles/graves-ophthalmopathy">Graves ophthalmopathy</a> or orbitopathy: affects ~20-25 % of cases</li>~~
+<a href="/articles/graves-ophthalmopathy">Graves ophthalmopathy</a> or orbitopathy: affects 20-25 % of cases</li>
~~-<a href="/articles/graves-encephalopathy">Graves encephalopathy</a> <sup>2</sup>~~
+<a title="encephalopathy associated with autoimmune thyroid disease" href="/articles/encephalopathy-associated-with-autoimmune-thyroid-disease">encephalopathy associated with autoimmune thyroid disease</a> (EAATD) <sup>2, 8</sup>
-</ul><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 effected 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><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>
~~-<li>thyroid recepter antibodies (TSI, TGI, TBII): positive</li>~~
+<li>thyroid receptor antibodies (TSI, TGI, TBII): positive</li>
~~-<li>the thyroid gland is often enlarged and can be hyperechoic</li>~~
~~-<li>the is a relative absence of nodularity in uncomplicated cases</li>~~
~~-<li>hyper vascular and may demonstrate a "<a href="/articles/thyroid-inferno">thyroid inferno</a>" pattern on colour Doppler <sup>1</sup>~~
+<li>thyroid gland is often enlarged and can be hyperechoic</li>
+<li>relative absence of nodularity in uncomplicated cases</li>
+<li>hypervascular; may demonstrate a "<a href="/articles/thyroid-inferno">thyroid inferno</a>" pattern on colour Doppler <sup>1</sup>
~~-</ul><h5>Scintigraphy</h5><ul>~~
+</ul><h5>Nuclear medicine</h5><ul>
-<a href="/articles/iodine-123"><strong>I </strong><sup><strong>123</strong></sup></a>: imaging performed at around 2-6 days. classically demonstrates homogeneously increased activity in an enlarged gland</li>
+<a href="/articles/iodine-123"><strong>I </strong><sup><strong>123</strong></sup></a>: imaging performed at around 2-6 days; classically demonstrates homogeneously increased activity in an enlarged gland</li>
~~-</ul><h4>Differential diagnoses for hyperthyroidism </h4><ul>~~
+</ul><h4>Differential diagnosis</h4><p>For hyperthyroidism consider: </p><ul>
~~-<li>toxic adenoma</li>~~
~~-<li>toxic multinodular goiter</li>~~
+<li>toxic <a href="/articles/thyroid-adenoma">thyroid adenoma</a>
+</li>
+<li>toxic <a href="/articles/multinodular-goitre">multinodular goiter</a>
+</li>
~~-</ul><h4>History and etymology</h4><p>It is named after <strong>Robert James Graves</strong>: Irish Surgeon (1796 -1853).</p>~~
+</ul><h4>History and etymology</h4><p>It is named after <strong>Robert James Graves</strong>,<strong> </strong>Irish Surgeon (1796-1853).</p><h4>Practical points</h4><ul><li>patients with Graves disease are at higher risk of <a href="/articles/iodinated-contrast-induced-thyrotoxicosis">iodinated contrast-induced thyrotoxicosis</a>
+</li></ul>

References changed:

7. Safer J. Thyroid Hormone Action on Skin. Dermatoendocrinol. 2011;3(3):211-5. <a href="https://doi.org/10.4161/derm.3.3.17027">doi:10.4161/derm.3.3.17027</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/22110782">Pubmed</a>
8. Tamagno G, Celik Y, Simó R et al. Encephalopathy Associated with Autoimmune Thyroid Disease in Patients with Graves' Disease: Clinical Manifestations, Follow-Up, and Outcomes. BMC Neurol. 2010;10(1):1-8. <a href="https://doi.org/10.1186/1471-2377-10-27">doi:10.1186/1471-2377-10-27</a>

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