Graves Disease

In this post we will learn about Graves Disease, its signs and symptoms and its management.

Grave’s disease is an autoimmune disease caused by production of autoantibodies that stimulate TSH(Thyroid Stimulating Hormone) receptor on thyroid cell membrane resulting in excessive synthesis and secretion of thyroid hormone.

Proptosis as seen in Graves Disease. Image Courtesy: Jonathan Trobe, M.D. – University of Michigan Kellogg Eye Center / CC BY (https://creativecommons.org/licenses/by/3.0)


Risk Factors


Gender: Females are more prone than men (10:1 ratio)

Irradiation, eg. radioactive iodine for multinodular goiter

Emotional stress

Pregnancy: iodine-containing drugs

Iodine and drugs: Amiodarone and iodine-containing contrast media may precipitate Grave’s disease

Genetic susceptibility: Role of hereditary factors is evidenced by increased incidence of other  autoimmune disorders in members of patient’s families.


Clinical Features


Signs

Warm skin

Tachycardia, atrial fibrilation in elderly

Tremor, hyper-reflexia

Lid lag

Lid retraction resulting in staring look

Proptosis

Exposure keratitis

Ophthalmoplegia

Failure of convergence (Mosbius sign)

Absence of wrinkling on looking upwards

Thyroid ophthalmopathy is a specific feature for Grave’s disease


Symptoms

Polyuria

Diarrhea/Defecation hyperclefecation

Oligomenorrhea

Ocular pressure on pain

Dyschromatopsia

Field loss

Loss of libido

Dyspnea

Loss of vision

Diplopia

Lacrimation

Heat intolerance

Sweating

Weight loss with increased appetite

Xerophthalmia

Puffy eyelids

Proptosis

Eyelid retraction


Investigations

T3 and T4 elevated

Ultrasonography of thyroid shows diffuse goiter

Serum cholesterol is low

I131 uptake is increased i.e. greater than 35% at 5 hours

Low TSH

ECG shows tachycardia, arrthymias, ST-T changes


Management


Treatment for Discomfort

Methylcellulose as artificial tears for dry eyes

Quit Smoking

Dark glasses with side frames

Eye ointment for the night


Medical Therapy

Iodine 131 leads to destruction of thyroid cells along with anti thyroid drugs

Prednisolone 60 mg daily

Reduction of lid edema by sleeping with head slightly raised

Beta blockers as propanolol 80-160 mg daily for 2-3 weeks

Anti thyroid drugs like propylthiouracil 300-450 mg/day, methimazole 100-150 mg 8 hourly,carbimazole 40-60 mg/day


Surgery

Subtotal thyroidectomy is done in severly affected cases. Before surgery patient should be made euthyroid by beta blockers and anti thyroid drugs. Two weeks before the surgery drugs should be stopped and lugo iodine is given to reduce the vascularity.