Grave’s Disease

Graves disease, also called as diffuse thyrotoxic goiter, is an autoimmune disorder that results in hyperthyroidism (over activity of the thyroid gland). It is a common cause of severe hyperthyroidism. The condition has been discovered by an Irish physician, Robert Graves about 150 years ago. Grave’s disease accounts for about 90 percent of cases presenting with hyperthyroidism. It commonly occurs during middle age and can affect children, adults and elderly. It involves a strong hereditary factor and commonly affects more number of females than males. Although, Graves’  disease can’t be cured; however, the associated symptoms like ophthalmopathy, hyperthyroidism, and psychiatric complications can be effectively treated.


Causes and risk factors

The most common cause of hyperthyroidism is Grave’s disease, which develops due to an abnormal immune function that forces the thyroid gland to secrete excess of thyroid hormone.

Graves’ disease occurs due to the malfunction of immune system that is programmed to release abnormal antibodies into the blood stream, which physiologically mimic the action of TSH.

The major factor that triggers the production of auto-antibody is not yet known; however, few cases develop TSH receptor auto antibodies due to genetic predisposition.

It has been believed that viral or bacterial infection may stimulate these antibodies to cross-react with the human TSH receptor, thus contributing for thyroid autoimmunity in patients with genetic susceptibility.

The production of aberrant antibodies may be influenced by heredity and other characteristics that increase susceptibility.

Graves’ disease can be triggered by different causes like trauma or surgery to the thyroid gland, infarction of a thyroid adenoma,and percutaneous injection of ethanol.

It is believed to be caused by both genetics and environmental factors, like stress.

Other triggering factors include medication therapies like interleukin (IL-4) and interferon (interferon beta-1b) therapy.

Incidence

Graves’ disease commonly affects women over 20 years and its incidence is higher in females when compared to males. However, it can develop at any age, regardless of gender.

Symptoms

  • Patients with Graves’ disease generally present with typical thyrotoxicosis symptoms.
  • Hyperthyroidism is commonly associated with symptoms like palpitation and tachycardia.
  • Classic features are not evident in all patients and aeuthyroid Graves disease has been detected in few patients.
  • Elderly patients present with fewer symptoms like hyperhidrosis,unexplained weight loss, or rapid heart beat.
  • Young adolescents may develop sudden paralysis that has been interlinked to thyrotoxic periodic paralysis.

The symptoms of Graves disease that affect various body systems, are as follows:

General

  • Fatigue
  • Weakness

Neuro muscular system

  • proximal muscle weakness
  • easy fatigability
  • periodic paralysis
  • Tremors

Dermatologic (integumen)

  • Onycholysis
  • Moist, warm, and fine skin
  • Sweating
  • Vitiligo
  • fine hair
  • alopecia
  • pretibial myxedema

Skeletal system

  • Back pain
  • Increased susceptibility to fractures

Cardiovascular or Respiratory system

  • Palpitations
  • Chest pain
  • Dyspnea on exertion
  • Edema

Gastrointestinal system

  • Increased bowel motility
  • Increased frequency of bowel movements

Renal system

  • Polydipsia
  • Polyuria

Ophthalmologic system

  • Tearing
  • photophobia
  • Gritty sensation in the eye
  • Eye pain
  • Protruding
  • Visual loss
  • Diplopia of the eye

Metabolic system

  • weight loss despite healthy appetite
  • Heat intolerance
  • Worsening diabetes control

Hematologic

  • Easy bruising

Psychiatric symptoms

  • Anxiety
  • Restlessness
  • Insomnia
  • Irritability

Endocrine/reproductive symptoms

  • Irregular menstrual periods
  • Decreased menstrual volume
  • Impotence
  • Gynecomastia
  • The physical symptoms of graves’ disease that are associated with thyrotoxicosis are as follows:
  • Dermopathy and ophthalmopathy are the clinical findings of Graves disease that are not related to hyperthyroidism.
  • Onycholysis becomes evident in the fourth and fifth fingernails.
  • Myxedematous skin changes in the pretibial regions that mimic the texture and color of an orange peel.
  • Diffuse enlargement of the thyroid gland including thyrotoxic signs and symptoms.

The physical findings based on various anatomic locations include:

  • General system –weight loss despite increased appetite,Increased basal metabolic rate
  • Head and neck- conjunctival irritation, lid lag, Chemosis, widening of the palpebral fissures, proptosis, lid retraction, visual loss in severe optic nerve involvement, impair edextraocular motion, and periorbital edema.
  • Skin – Increased sweating, vitiligo, pretibial myxedema, alopecia, fine hair, warm, and most skin
  •  Neck –Smooth, diffuse enlargement of the thyroid gland, thyroid bruits, palpablethyroid nodules an rarely, thrills can be detected.
  • Abdomen – Hyperactive bowel movements
  • Chest – tachypnea, Gynecomastia, ectopic beats, tachycardia, hyperdynamic precordium, murmur, S3, S4 heart sounds, irregular heart rate and rhythm.
  • Extremities – acropachy, edema, onycholysis
  • Musculoskeletal symptoms- Lordosis, Kyphosis, reduced height, hypokalemic periodic paralysis anproximal muscle weakness.
  • Psychiatric – anxiety, restlessness, insomnia, irritability, and depression
  • Neurologic symptoms–bilateral fine hand tremors and hyperactive deep tendon reflexes

Treatment for Graves’ disease

  • The main aim of the treatment is to control the hyperactive thyroid gland.
  • Symptomatic treatment includes Beta-blockers like propranolol to control anxiety, pounding heart beat and sweating.
  • Anti-thyroid medications (like methimazole or propylthiouracil) and Radioactive iodine are recommended
  • Thyroid hormone replacement therapy should be taken for a lifetime when treated with surgery or radiation.

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