GRAVES DISEASE

Graves' disease is an autoimmune disease in which the patient's own immune

system attacks the thyroid gland, causing it to produce too much thyroid hormones.
Most common form of HYPERTHYROIDISM.
The thyroid gland is part of the endocrine system, and is located in the neck, below
the Adam's apple. It produces hormones which help to regulate growth and the rate
of chemical reactions by which the body uses energy. The thyroid gland produces
thyroxine and triiodothyronine.
Thyroxine affects many body systems and has a key role in regulating our body's
metabolic rate - the rate at which chemical reactions occur in our body; the rate at
which our bodies break things down to produce energy, and build new tissue
(metabolism). When thyroxine levels are high the patient's metabolic rate increases;
this can have an effect on their physical appearance as well as moods.
Healthy people's immune systems attack pathogens; organisms and substances
that are bad for us, such as some bacteria, viruses, parasites, cancer cells and
fungi. If the person's immune system starts attacking good tissue they
have an autoimmune disease - the immune system is attacking parts of the
person's body that are needed for good health.
The antibody associated with Graves' disease thyrotropin receptor antibody
(TRAb) acts like the regulatory pituitary hormone. That means that TRAb
overrides the normal regulation of the thyroid, causing an overproduction of thyroid
hormones (hyperthyroidism).
Common signs and symptoms of Graves' disease include:

Anxiety and irritability

A fine tremor of your hands or fingers

Heat sensitivity and an increase in perspiration or warm, moist skin

Weight loss, despite normal eating habits

Enlargement of your thyroid gland (goiter)

Change in menstrual cycles

Erectile dysfunction or reduced libido

Frequent bowel movements

Bulging eyes (Graves' ophthalmopathy)

Thick, red skin usually on the shins or tops of the feet (Graves' dermopathy)

Rapid or irregular heartbeat (palpitations)

Graves' ophthalmopathy

About 30 percent of people with Graves' disease show some signs and symptoms of
a condition known as Graves' ophthalmopathy. In Graves' ophthalmopathy,
inflammation and other immune system events affect muscles and other tissues
around your eyes. The resulting signs and symptoms may include:

Bulging eyes (exophthalmos)

Gritty sensation in the eyes

Pressure or pain in the eyes

Puffy or retracted eyelids

Reddened or inflamed eyes

Light sensitivity

Double vision

Vision loss

Graves' dermopathy
An uncommon manifestation of Graves' disease, called Graves' dermopathy, is the
reddening and thickening of the skin, most often on your shins or the tops of your
feet.
Risk factors:

Family history. Because a family history of Graves' disease is a known risk

factor, there is likely a gene or genes that can make a person more
susceptible to the disorder.

Gender. Women are much more likely to develop Graves' disease than are
men. For every male with Graves' disease there are seven females with the
disease

Age. Graves' disease usually develops in people younger than 40.

Other autoimmune disorders. People with other disorders of the immune

system, such as type 1 diabetes or rheumatoid arthritis, have an increased
risk.

Emotional or physical stress. Stressful life events or illness may act as a

trigger for the onset of Graves' disease among people who are genetically
susceptible.

Pregnancy. Pregnancy or recent childbirth may increase the risk of the

disorder, particularly among women who are genetically susceptible.

Smoking. Cigarette smoking, which can affect the immune system, increases
the risk of Graves' disease. Smokers who have Graves' disease are also at
increased risk of developing Graves' ophthalmopathy.

Complications:

Heart problems - the patient may develop tachycardia (fast

heartbeat), atrial fibrillation (a heart rhythm disorder), and congestive heart
failure (the heart fails to pump enough blood for the whole body's
requirements). With the right kind of treatment these complications are
reversible.

Brittle bones - if the patient does not receive treatment their bones will
become weak and they may develop osteoporosis. When calcium and mineral
levels in bones drop they become weak. Overproduction of thyroid hormone
interferes with the body's ability to get calcium into bones.

Thyrotoxic crisis/ Thyroid storm/ Accelerated Hyperthyroidism - this is

a sudden increase in the severity of signs and symptoms. The patient may
develop a fever, accelerated heartbeat, profuse sweating, vomiting, diarrhea,
severe weakness, seizures, severe low blood pressure, confusion and even
delirium. This rare complication should be treated immediately.

Pregnancy issues- Possible complications of Graves' disease during

pregnancy include miscarriage, preterm birth, fetal thyroid dysfunction, poor
fetal growth, maternal heart failure and preeclampsia. Preeclampsia is a
maternal condition that results in high blood pressure and other serious signs
and symptoms.

Test and Diagnosis

Physical examination - the GP (general practitioner, primary care

physician) or specialist examines the patient's eyes to see whether they are
bulging or irritated. The thyroid is examined to determine whether it is
enlarged. The doctor will also check the patient's heart rate and blood
pressure. The physician will check for signs of trembling of the hands or
fingers (tremor). During the interview the patient will be asked about their
symptoms, medical and family medical histories.

Blood test - these are carried out to find out what the levels of TSH (thyroidstimulating hormone) and thyroxine are. THS is a hormone which stimulates
the thyroid gland - it is produced and released by the pituitary gland.
Elevated levels of TRAb, an antibody, mimics TSH, making the thyroid gland
overproduce thyroxine, even when TSH levels are low. A doctor may diagnose
Graves' disease if the patient has low levels of TSH and high levels of
thyroxine.

Radioactive iodine uptake - iodine is needed by the human body to

produce thyroxine. The doctor can determine the rate at which the thyroid

gland takes up iodine by giving the patient a small amount of radioactive

iodine and then measuring the level of it in the thyroid gland after a set
period. If the uptake of radioactive iodine is high it means that the patient's
thyroid gland is producing excessive amounts of thyroxine - this occurs in
Graves' disease. In some other causes of hyperthyroidism the uptake of
iodine is low.

Ultrasound- Ultrasound uses high-frequency sound waves to produce

images of structures inside the body. Ultrasound can show if the thyroid gland
is enlarged, and is most useful in people who can't undergo radioactive iodine
uptake, such as pregnant women.

Imaging tests- If the diagnosis of Graves' ophthalmopathy isn't clear from a

clinical assessment, your doctor may order an imaging test, such as CT scan,
a specialized X-ray technology that produces thin cross-sectional images.
Magnetic resonance imaging (MRI), which uses magnetic fields and radio
waves to create either cross-sectional or 3-D images, may also be used.

Treatment:
There are no medications or treatment currently available today that can stop the
patient's immune system from attacking the thyroid gland and causing Graves'
disease. However, a lot can be done to ease symptoms and lower the production of
thyroxine or block its action. The possible treatments include:
Beta blockers - examples include propranolol (Inderal), atenolol (Tenormin),
metoprolol (Lopressor) and nadolol (Corgard). Beta blockers are generally effective
medications for relieving the signs and symptoms of hyperthyroidism, such as
accelerated heartbeat, anxiety and nervousness, and tremors..
Anti-thyroid drugs - examples include propylthiouracil and methimazole
(Tapazole). They prevent the thyroid gland from producing excessive amounts of
thyroid hormone
Radioactive iodine treatment - iodine is needed for the gland to produce thyroid
hormone. If a patient receives radioactive iodine it soon accumulates in the thyroid
gland. The radioactivity slowly destroys the overactive thyroid cells, resulting in a
smaller thyroid gland, and a lower production of thyroid hormone.
Surgery - this involves surgically removing the thyroid gland (thyroidectomy)
Graves' ophthalmopathy (when eyes are affected)
Dry eyes - patients with mild symptoms will most likely be prescribed artificial
tears for daytime use and a lubricating gel to help keep eyes moist during sleep.
Drugs - corticosteroids to reduce swelling behind the eyes.
Orbital decompression surgery - the bone between the orbit (eye socket) and
the sinuses is removed, giving the eyes more space so they can move back in.

Eye muscle surgery - the muscle that is attached to the eyeball is cut and
reattached further back, giving the patient better eye alignment and movement.
Prisms - prisms in glasses may correct double vision.
Orbital radiotherapy - the aim here is to destroy tissue behind the eyes by
targeting X-rays over a course of several days.

Graves' dermopathy
If the disease affects your skin (Graves' dermopathy), use over-the-counter creams
or ointments containing hydrocortisone to relieve swelling and reddening. In
addition, using compression wraps on your legs may help.