Graves' disease

Photograph showing a classic finding of Graves' Disease, proptosis and lid retraction. Jonathan Trobe, M.D. - University of Michigan Kellogg Eye Center

Graves disease, also known as Graves-Basedow disease, is an autoimmune disorder that can manifest in a variety of ways, including hyperthyroidism (overactive thyroid hormone production), infiltrative exophthalmos (protrusion of one or both eyes and associated problems), and infiltrative dermopathy (inflammation of the skin). (a skin condition usually affecting the lower extremities).

Graves' disease is characterized by proptosis and lid retraction. Jonathan Trobe, M.D. - Kellogg Eye Center, University of Michigan|600px]]

Hyperthyroidism

The most frequent cause of hyperthyroidism is Graves-Basedow disease. The condition is associated with an antibody-mediated form of autoimmunity, but the cause of the reaction is currently unclear.

Epidemiology

Graves' disease occurs eight times more frequently in women than in males. It is most prevalent in middle age, but can also affect adolescents, expectant women, menopausal women, and those over the age of 50.

Pathophysiology

Graves-Basedow disease symptoms include fatigue, weight loss (despite a healthy appetite), tachycardia, heat intolerance, muscle weakness, palpitations, increased bowel activity, emotional lability, and restlessness. In premenopausal women, the number of menstrual periods may decrease. (oligomenorrhea). Due to the presence of similar antibodies that stimulate the thyroid and react with the eye muscles, patients may develop an enlargement of the ocular muscles, causing forward movement of the eyeball (proptosis, also known as exophthalmos) and inflammation of the tissues surrounding the eye. The enlargement of the eye muscles may impede appropriate eye movement and coordination, resulting in double vision and a disparity between the relative positions of both eyes.

Graves' ocular disease

The ocular manifestations of Graves-Basedow disease are more prevalent in smokers and tend to aggravate or manifest for the first time after radioiodine therapy for the thyroid condition. This common misconception may stem from the fact that hyperthyroidism from other causes can cause eyelid retraction or eyelid lag (so-called hyperthyroid stare), which can be confused with the general appearance of proptosis/exophthalmos, even though the globes do not actually protrude in other causes of hyperthyroidism. In addition, both conditions may coexist in patients with Graves' disease and hyperthyroidism.

Graves-Basedow disease's hyperthyroidism may be treated with methimazole or propylthiouracil (PTU), which inhibit the production of thyroid hormone, or with radioactive iodine. Surgical removal of the thyroid is an additional option, but still requires preoperative treatment with methimazole or PTU to render the patient "euthyroid" (i.e. normothyroid) prior to surgery, as it is hazardous to operate on a hyperthyroid patient. Radioactive iodine (I-131) therapy is the most prevalent treatment in the United States and many other countries. In Japan, thyroid-blocking drugs and/or surgical thyroid removal are more commonly used as definitive treatments than radioactive iodine, possibly due to the widespread dread of radioactivity among many Japanese.

The invention of radioactive iodine (I-131) in the early 1940s and its ubiquitous use as a treatment for Graves' Disease have led to a gradual decline in the use of surgical thyroidectomy for this condition. RAI therapy is effective, less expensive, and avoids the tiny but real risks associated with surgery. To be effective, antithyroid medications must be administered for six months to two years. Even so, the hyperthyroid condition may recur after drug discontinuation. White blood cell count reduction is one of the potentially fatal side effects of antithyroid drugs.

The patient may experience hyperstimulation, restlessness, heat intolerance, tremor, palpitations and cardiac dysrhythmia, increased bowel activity, and emotional lability as a result of excessive thyroid hormone production. President George H.W. Bush developed new atrial fibrillation and was diagnosed with Graves' disease-related hyperthyroidism in 1991. He was treated with radioactive iodine at Walter Reed Medical Center. Interestingly, the president's wife, Barbara Bush, also contracted the disease around the same period, resulting in severe infiltrative exophthalmos and a cosmetic alteration to the appearance of her eyes.

Signs and symptoms

Graves-Basedow disease is distinguished by the triad of hyperthyroidism, goiter, and exophthalmos. (bulging eyeballs).

Numerous symptoms and indications are associated with Graves' disease as a result of the multiple physiological actions of thyroid hormone:

• Cardiac: cardiac arrhythmias (especially atrial fibrillation), tachycardia (increased heart rate), collapsing pulse and widened pulse pressure (difference between systolic and diastolic BP), and congestive cardiac failure with peripheral edema, ascites, anasarca.
• Endocrine: weight loss in the presence of increased appetite, intolerance to heat, and an increased basal metabolic rate.
• Dermatological: profuse perspiration, thyroid acropachy (clubbing) of the fingernails, onycholysis (fingernail destruction), palmar erythema, and pretibial myxedema. (3 to 5 percent of Graves' patients, not to be confounded with hypothyroidism myxedema)
• Neurological: tremor (particularly evident when the arms are extended), anxiety, weakness, headache, proximal myopathy (difficulty rising from a chair or squatting position), and hyperactive deep tendon reflex.es
• Gastrointestinal: diarrhea (common), vomiting (rare)
• Ophthalmological: thyroid eye disease (TED) is characterized by lid retraction (Dalrymple sign) above the superior corneoscleral limbus, lid lag (von Graefe sign), exophthalmos (globe forward displacement), periorbital swelling, and chemosis. If periorbital enlargement presses on the optic nerve, visual field defects may be present. The patient may experience dry eye owing to insufficient lid closure.
• Stomatological: multiple dental caries, parodontitis (rare).
• The thyroid cyclone is a severely manifested and sometimes life-threatening form of the disease.

Diagnosis

The medical laboratory determines thyroid hormone (thyroxine or T4, triiodothyronine or T3) and thyroid-stimulating hormone (TSH) based on signs and symptoms. Free T4 and Free T3 are significantly elevated, while TSH is suppressed as a result of negative feedback. Possible to detect an elevated protein-bound iodine level. Occasionally, X-rays reveal a sizable goiter.

Antibodies that stimulate the thyroid can be detected serologically. These autoantibodies, also known as thyroid receptor antibodies (TRAb), bind to and activate the TSH receptor, resulting in uncontrolled thyroid hormone production. Other diagnostic tests, such as thyroid ultrasound or radioactive iodine uptake, can help corroborate the diagnosis and determine the disease's severity.

Treatment

Graves-Basedow disease is treated based on the severity of the condition and the patient's specific requirements. There are three primary alternatives for treatment:

Antithyroid drugs include: Methimazole and propythiouracil (PTU) are used to inhibit the production of thyroid hormone. Before undergoing other treatments, such as surgery or radioiodine therapy, these medications may be administered as a long-term or short-term treatment to restore normal thyroid function.

• "Radioiodine treatment:" Iodine-131 is administered orally and is ingested by the thyroid gland. The radioactive iodine destroys overactive thyroid cells, thereby decreasing thyroid hormone production. This treatment frequently results in hypothyroidism, which requires lifelong replacement therapy with thyroid hormone.
• Surgery: Thyroidectomy is an option for patients who cannot tolerate antithyroid medications or radioiodine therapy or who have a large goiter that is compressing adjacent structures. As with radioiodine therapy, surgery frequently results in hypothyroidism, necessitating everlasting replacement therapy with thyroid hormone.

In addition to these primary treatments, beta-blockers may be prescribed to ameliorate certain hyperthyroidism symptoms, such as a rapid heart rate, palpitations, and tremors. In severe instances, Graves' eye disease may be treated with corticosteroids, lubricating eye drops, or surgery.

Graves-Basedow disease patients must have regular checkups with their healthcare provider to monitor their thyroid function and modify their treatment as necessary.

Prognosis

The prognosis for Graves-Basedow disease varies based on the patient and the chosen treatment modality. Many people with Graves-Basedow disease can attain long-term control of their thyroid function and maintain a high quality of life with proper treatment and management. Some patients, however, may experience a relapse of hyperthyroidism or develop hypothyroidism as a consequence of their treatment. It is imperative that patients maintain regular follow-up appointments with their healthcare provider in order to monitor their thyroid function and modify their treatment as necessary.

Complications

Graves-Basedow disease can result in several complications if left untreated, including:

• Heart conditions: Untreated hyperthyroidism can cause atrial fibrillation, congestive heart failure, and other cardiovascular complications.
• Over time, untreated hyperthyroidism can result in a decrease in bone mineral density, thereby increasing the risk of fractures.
• "Thyroid tempest:" This is a rare but life-threatening complication characterized by an abrupt deterioration of hyperthyroidism symptoms, including fever, rapid heart rate, and severe weakness. It requires urgent medical attention.
• Graves' eye disease can cause vision issues, eye discomfort, light sensitivity, and in severe cases, vision loss.

Prevention

There is no known method to prevent Graves-Basedow disease, but early diagnosis and treatment can reduce the risk of complications and improve the patient's overall quality of life. Individuals with a family history of thyroid disorders or other autoimmune diseases must undergo regular checkups with a healthcare professional.

Living with Grave's disease

Graves-Basedow disease must be managed with ongoing care and observation by a healthcare provider. To ensure that their thyroid function is well-controlled, it is crucial that patients adhere to their prescribed treatment plan and attend regular follow-up appointments. In addition, adopting a healthy lifestyle, which includes a balanced diet, regular exercise, and stress management techniques, can improve overall health and lessen the impact of Graves' disease on daily life. In addition to being aware of the signs and symptoms of potential complications, patients should seek medical attention if their health deteriorates.

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