Graves' disease may present clinically with one of the following characteristic signs:
exophthalmos (protuberance of one or both eyes)
a non-pitting edema (pretibial myxedema), with thickening of the skin usually found on the lower extremities
fatigue, weight loss with increased appetite, and other symptoms of hyperthyroidism
rapid heart beats
muscular weakness
The two signs that are truly 'diagnostic' of Graves' disease (i.e., not seen in other hyperthyroid conditions) are exophthalmos and non-pitting edema (pretibial myxedema). Goiter is an enlarged thyroid gland and is of the diffuse type (i.e., spread throughout the gland). Diffuse goiter may be seen with other causes of hyperthyroidism, although Graves' disease is the most common cause of diffuse goiter. A large goiter will be visible to the naked eye, but a smaller goiter (very mild enlargement of the gland) may be detectable only by physical exam. Occasionally, goiter is not clinically detectable but may be seen only with CT or ultrasound examination of the thyroid.
Another sign of Graves' disease is hyperthyroidism, i.e., overproduction of the thyroid hormones T3 and T4. Normothyroidism is also seen, and occasionally also hypothyroidism, which may assist in causing goiter (though it is not the cause of the Graves disease). Hyperthyroidism in Graves' disease is confirmed, as with any other cause of hyperthyroidism, by measuring elevated blood levels of free (unbound) T3 and T4.
Other useful laboratory measurements in Graves' disease include thyroid-stimulating hormone (TSH, usually low in Graves' disease due to negative feedback from the elevated T3 and T4), and protein-bound iodine (elevated). Thyroid-stimulating antibodies may also be detected serologically.
Biopsy to obtain histiological testing is not normally required but may be obtained if thyroidectomy is performed.
Differentiating two common forms of hyperthyroidism such as Graves' disease and Toxic multinodular goiter is important to determine proper treatment. Measuring TSH-receptor antibodies with the h-TBII assay has been proven efficient and was the most practical approach found in one study.
Palpitations Tachycardia (rapid heart rate: 100-120 beats per minute, or higher) Arrhythmia (irregular heart beat) Hypertension (Raised blood pressure) Tremor (usually fine shaking, e.g., hands) Hyperhidrosis (excessive sweating) Heat intolerance Polyphagia (increased appetite) Unexplained weight loss despite increased appetite Dyspnea (shortness of breath) Muscle weakness (especially in the large muscles of the arms and legs) and degeneration Insomnia (inability to get enough sleep
Diminished/changed sex drive Insomnia (inability to get enough sleep) Palpitations Tachycardia (rapid heart rate: 100-120 beats per minute, or higher) Arrhythmia (irregular heart beat) Hypertension (Raised blood pressure) Tremor (usually fine shaking, e.g., hands) Hyperhidrosis (excessive sweating) Heat intolerance Polyphagia (increased appetite) Unexplained weight loss despite increased appetite Dyspnea (shortness of breath) Muscle weakness (especially in the large muscles of the arms and legs) and degeneration Diminished/changed sex drive
Eye pain, irritation, tingling sensation behind the eyes or the feeling of grit or sand in the eyes Swelling or redness of eyes or eyelids/eyelid retraction Sensitivity to light Decrease in menstrual periods (oligomenorrhea), irregular and scant menstrual flow (amenorrhea) Difficulty conceiving/infertility/recurrent miscarriage Chronic sinus infections Lumpy, reddish skin of the lower legs (pretibial myxedema) Increased bowel movements or diarrhea Panic attacks Protruding eyeballs
Eye disease
Thyroid-associated ophthalmopathy is one of the most typical symptoms of Graves' disease. It is known by a variety of terms, the most common being Graves' ophthalmopathy. Thyroid eye disease is an inflammatory condition, which affects the orbital contents including the extraocular muscles and orbital fat. It is almost always associated with Graves' disease but may rarely be seen in Hashimoto's thyroiditis, primary hypothyroidism, or thyroid cancer.
The ocular manifestations that are relatively specific to Grave's disease include soft tissue inflammation, proptosis (protrusion of one or both globes of the eyes), corneal exposure, and optic nerve compression. Also seen, if the patient is hyperthyroid, (i.e., has too much thryoid hormone) are more general manifestations, which are due to hyperthyroidism itself and which may be seen in any conditions that cause hyperthyroidism (such as toxic multinodular goiter or even thyroid poisoning). These more general symptoms include lid retraction, lid lag, and a delay in the downward excursion of the upper eyelid, during downward gaze.
It is believed that fibroblasts in the orbital tissues may express the Thyroid Stimulating Hormone receptor (TSHr). This may explain why one autoantibody to the TSHr can cause disease in both the thyroid and the eyes
Lid Retraction
Proptosis
Graves Disease
Grave's Ophthalmolopathy is the most common caused of unilateral or bilateral proptosis in adults.
It commonly occurs between the ages of 25-50, although it may also present in adolescents.
Diagnosis is made based on clinical findings including proptosis, eyelid retraction, restrictive myopathy and possibly compressive optic neuropathy. It is often grouped into two independent manifestations of this syndrome:
Type I and Type II orbitapathy, but may overlap
More frequent signs:
Less frequent signs:
lid lag (upper and lower)
exophthalmos
diplopia
lid edema
chemosis
conj injection over recti
increased IOP with elevation
keratopathy
closed lid tremor
infrequent blinking
difficult eversion upper lid
bruit over eye
decrease forehead wrinkling with upgaze
increased hippus
pigmented lids
Werner's Classification
NO SPECS, with each class in four grades 0-4, a, b, c: mild to severe
0 No S/S
1 Only signs (lid retraction)
2 Soft tissue involved (chemosis, grit, etc)
3 Proptosis (min <23, mod, marked >28)
4 EOM involved
5 Corneal involvement
6 Sight loss
Symptom
Type I
Type II
Sex predilection
Female
Proptosis
Symmetric
Unilateral or bilateral
Eyelid retraction
Symmetric
Unilateral or bilateral
Orbital inflammation
Minimal
Extraocular muscle inflammation/ restriction
Minimal
Frequent
Chemosis
Unusual
Usual
diplopia
Unusual
Frequent
Compressive optic neuropathy
Unusual
Frequent
Diagnosis is made on these clinical findings and may be confirmed on CT which shows enlargement of multiple extraocular muscles most commonly the inferior and medial rectus. See earlier page.
Systemic thyroid may be hyperthyroid, hypothyroid, or euthyroid. Treatment may include topical lubrication, systemic steroids, orbital decompression surgery, extraocular muscle adjustment, eyelid recession surgery and radiation therapy.
Graves' disease is an autoimmune disease. It most commonly affects the thyroid, causing it to grow to twice its size or more (goiter), be overactive, with related hyperthyroid symptoms such as increased heartbeat, muscle weakness, disturbed sleep, and irritability. It can also affect the eyes, causing bulging eyes (exophthalmos). It affects other systems of the body, including the skin and reproductive organs. It affects up to 2% of the female population, often appears after childbirth, and has a female:male incidence of 5:1 to 10:1. It has a strong hereditary component; when one identical twin has Graves' disease, the other twin will have it 25% of the time. Smoking and exposure to second-hand smoke is associated with the eye manifestations but not the thyroid manifestations. Diagnosis is usually made on the basis of symptoms, although thyroid hormone tests may be useful, particularly to monitor treatment.
An abscess (Latin: abscessus) is a collection of pus (dead neutrophils) that has accumulated in a cavity formed by the tissue on the basis of an infectious process (usually caused by bacteria or parasites) or other foreign materials (e.g. splinters, bullet wounds, or injecting needles). It is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body
A goitre (BrE), or goiter (AmE) (Latin gutteria, struma), also called a bronchocele, is a swelling in the thyroid gland,which can lead to a swelling of the neck or larynx.
Exophthalmos (also called exophthalmia) is a bulging of the eye anteriorly out of the orbit. Exophthalmos can be either bilateral (as is often seen in Graves' Disease) or unilateral (as is often seen in an orbital tumor). Measurement of the degree of exophthalmos is performed using an exophthalmometer. Complete or partial dislocation from the orbit is also possible from trauma or swelling of surrounding tissue resulting from trauma
Edema is an abnormal accumulation of fluid beneath the skin, or in one or more cavities of the body. Generally, the amount of interstitial fluid is determined by the balance of fluid
Hyperthyroidism is the term for overactive tissue within the thyroid gland, resulting in overproduction and thus an excess of circulating free thyroid hormones: thyroxine (T4), triiodothyronine (T3), or both. Thyroid hormone is important at a cellular level, affecting nearly every type of tissue in the body
Hypothyroidism is the disease state in humans and in animals caused by insufficient production of thyroid hormone by the thyroid gland. Cretinism is a form of hypothyroidism found in infants
A biopsy is a medical test involving the removal of cells or tissues for examination. It is the removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically. When an entire lump or suspicious area is removed, the procedure is called an excisional biopsy. When only a sample of tissue is removed with preservation of the histological architecture of the tissue’s cells, the procedure is called an incisional biopsy or core biopsy. When a sample of tissue or fluid is removed with a needle in such a way that cells are removed without preserving the histological architecture of the tissue cells, the procedure is called a needle aspiration biopsy
The state of having normal thyroid gland function. Examples of a nonfunctioning thyroid gland may be hypothyroidism, hyperthyroidism, or thyroiditis.
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