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Graves’ disease

  • An autoimmune disease characterised by hyperthyroidism due to thyroid stimulating antibodies

Etiology/Pathophysiology

  • Genetic/hereditary component – associated with HLA DR3
  • Patient produces auto-antibodies after infection
    • Some bacteria (Yersinia enterocolitica) have TSHR-like proteins on their cell wall – leads to antigen mimicry
    • Auto-antibodies against the TSHR are produced
      • They stimulate the thyroid gland to produce and release thyroid hormone
  • Goitre in Graves’ disease is due to
    • Action of the TSHR-antibodies
    • Inflammation and lymphocytic infiltration
  • Retro-orbital swelling from lymphocyte and macrophage infiltration leads to exophthalmos
 Arterial supply of the Thyroid gland
  • Superior thyroid artery – branch of external carotid artery
  • Inferior thyroid artery – branch of the thyrocervical trunk
  • Thyroid ima artery – branch of the subclavian artery

Clinical presentation

  • Diffusely enlarged thyroid gland – soft and symmetrical
  • Exophthalmos and eye issues
    • Tearing, gritty sensation, photophobia, eye pain
    • Diplopia
    • Optic nerve compression – vision loss
    • Lid retraction
  •  Graves’ dermopathy – red swollen skin on shins and dorsal feet
  • Nail clubbing
  • Other signs of hyperthyroidism
    • Agitation, palpitations, tachycardia
    • Feeling hot, weight loss, hair loss, fatigue, insomnia

Diagnosis

  • Detection of anti-TSHR antibodies
  • Low TSH and high free T3/T4
  • Thyroid uptake scan 

    – diffuse high uptake

    • Increased radioactive iodine uptake (in other causes of hyperthyroid this is decreased)

Treatment

  • Antithyroid drugs – for patients under 40 years old
    • Carbimazole – inhibits formation of thyroid hormones
      • Side effects – nausea, GI upset, rash, pruritis, agranulocytosis
    • Propylthiouracil (PTU)
      • Side effects – agranulocytosis
    • Beta blocker – controls signs of palpitations and tachycardia
      • Propanolol – also blocks conversion of T4 to T3
  • Radioactive iodine – for older patients
    • May worsen eye disease and cause hypothyroidism
  • Glucocorticoids – may improve eye issues
  • Surgical thyroidectomy – total or subtotal
    • If large goitre pressing on trachea
    • In suspicious nodules or suspected cancers
    • Side effects – damaged recurrent laryngeal nerve, hypoparathyroidism
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