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  • • Diffusely hypersecretory goiter with resultant increased levels of thyroid hormone in the blood

    • Nervousness, weight loss with increased appetite, heat intolerance, increased sweating, muscular weakness and fatigue, increased bowel frequency, polyuria, menstrual irregularities, infertility

    • Goiter, tachycardia, atrial fibrillation, warm moist skin, thyroid thrill and bruit, cardiac flow murmur, gynecomastia

    • Eye signs include:

    • -Stare

      -Lid lag

      -Exophthalmos

    • Thyroid-stimulating hormone (TSH) low or absent

    • Increased radioactive iodine uptake

    • Increased tri-iodothyronine (T3) and thyroxine (T4)

    • Abnormal T3 suppression test

    • Elevated thyroid-stimulating immunoglobulin

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Epidemiology

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  • • 85% of all hyperthyroid cases

    • Peak age of onset is fourth decade

    • Incidence: 23 per 100,000

    • Female:male ratio of 4:1 to 5:1

    • 50% of patients show clinical signs of ophthalmopathy

    • 50% of patients have myopathy that presents as proximal muscle weakness

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Symptoms and Signs

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  • • Nervousness, increased diaphoresis, heat intolerance, tachycardia, palpitations, fatigue, and weight loss

    • Nodular, multinodular, or diffuse goiter on physical exam

    • Flushed and staring appearance

    • Warm, thin, and moist skin

    • Fine hair

    • Possible exophthalmos

    • Pretibial myxedema

    • Vitiligo

    • Shortened Achilles reflex time

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Laboratory Findings

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  • • Suppressed TSH

    • Elevated T3, free T4, and radioactive iodine uptake

    • Failure to suppress radioiodine uptake with exogenous T3

    • Failure of rise in TSH with thyrotropin-releasing hormone (TRH) administration

    • High thyroid-stimulating immunoglobulin level

    • Low serum cholesterol

    • Lymphocytosis

    • Occasional hypercalcemia, hypercalciuria, or glycosuria

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Imaging Findings

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  • • Diffuse increased uptake on radioactive iodine scan

    • Thyroid US reveals an enlarged gland, with or without nodules, and high vascular flow

    • Orbital US, CT, or MRI can evaluate extraocular muscles, retrobulbar soft tissue, and optic nerve

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  • • Clinical manifestations may go through periods of exacerbation and remission

    • Graves disease is an autoimmune disease in which antibodies are directed against the TSH receptor

    • Pathogenesis of ocular problems in Graves disease is unclear

    • Eye complications may begin before and continue after thyroid dysfunction

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Rule Out

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  • • Anxiety neurosis

    • Pheochromocytoma

    • Primary ophthalmopathy (eg, orbital tumors)

    • Thyrotoxicosis factitia

    • Thyroiditis

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  • • Complete history (including family) and physical examof the thyroid gland

    • Thyroid function tests

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  • • Antithyroid drugs, radioactive iodine, or thyroidectomy

    • Treatment of ocular problems of Graves disease include:

    • -Maintenance of euthyroid state

      -Protecting the eyes from light and dust

      -Elevating the bed

      -Diuretic use

      -Methylcellulose or guanethidine eye drops

      -Systemic glucocorticoids

      -Ophthalmologic surgery

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Surgery

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Indications

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  • • Very large goiter or multinodular goiter with relatively low radioactive iodine uptake

    • Thyroid nodule that may be malignant

    • Patients with ophthalmopathy

    • Pregnant patients or children

    • Women who wish to become pregnant ...

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