Graves' Disease

 

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Original Editors - Erin Shinkle from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Graves’ is classified as an autoimmune disease that affects the thyroid gland. It causes goiters, hyperthyroidism, ophthalmopathy, and occasionally dermopathy.(ginsberg) Graves'  disease is known for increasing the thyroid stimulating hormone which either raises the thyroxine (T4) levels which leads to hyperthyroidism symptoms or in approximately 10% of  graves' disease cases there is a raise triiodothyronine (T3) levels with both TSH and T4 levels normal which is a possible precurser to graves disease.(DD and Ginsberg)

Prevalence

Graves’ disease is more prevalent in the Caucasian race affecting more women than men at a ratio of 4:1 and ages range from 30-60years (Hemmiki and DD). Graves’ disease accounts for 85% of all cases of hyperthyroidism. (Pathology)

Characteristics/Clinical Presentation

Goiter, Exophthalmos, tremors, tachycardia with palpitations, heat intolerances, weight loss, increased deep tendon reflexes, weakness and muscle atrophy, increased cardiac output, myasthenia gravis, thin hair, warm moist skin, sensitivity to light, dysphasia, diarrhea, amenorrhea, polyuria, and many other presentations, some of which may not be as common and more subtle. (pathology)

Most common diagnostic symptom

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Associated Co-morbidities

Rhuematoid arthritis is one of the major associated autoimmune diseases but a raise in incidence for a co-morbidity of any autoimmune diseases. (Boelaert) Recommendation for futher autoimmune disease screening may be warrented with the diagnosis of Graves' disease. 

There is also an increased risk of cancer in the thyroid nodules associated with Graves' disease and further ultrasonography imaging and/or biopsy may be needed for further testing if suspected malignancy. (Ginsberg and Pathology)

Medications

Antithyroid drugs have the main effect of inhibition of thyroid hormones as well as a secondary purpose of reduction of thyrotropin-receptor antibodies and increasing supressor T-cells. These drugs are used mainly for controlling the thyroid in hopes to create a stable thyroid and have a remission period rom Graves' Disease (franklyn). The three main medications are Methimazole, Carbimazole, and Propylthiouracil. The most perferred medication is methimazole, however, there are no significant differences among the antithyroid drugs in their success rates.(cooper)

Beta Adrenergic- Antagonist Drugs is used for treatment of symptoms such as tremors, anxiety, and palpitations. This medication is used as an adjunct therapy to other means of management for Graves disease. (cooper)

Inorganic Iodide is used only for short term reduction of thyroid hormones lasting effects from days to a few weeks. (cooper)

Radioiodine Therapy is becoming a more popular means of treatment which is used to destroy thyroid tissue with the ultimate goal of balanced thyroid hormones or hypothyriodism.(Cooper)

Diagnostic Tests/Lab Tests/Lab Values

Thyroid blood serum testsare taken A positive test results include a decreased or normal TSH levels, elevated free thyroxine t4 diagnosis of hyperthyriodism. To specify graves disease Radioiodine uptake test is used.(Ginsberg)

Thyroid stimulating Hormone Antibodies (TRAb) and thyroid peroxidase autoantibodies (TPOAb) may be found in most patients, but is not needed for specific diagnosis since most patients are diagnosed with blood serum tests and symptomology. (Fukushima)

Etiology/Causes

Has both genetic causes, lack of suppressor t-cells causing increase in TSH receptor antibodies, and environmental causes which includes, but not limited to the following: stress, smoking, post pardum, and infections (Hemminki and ginsburg)

Systemic Involvement

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Medical Management (current best evidence)

The current best management of Graves' disease varies upon several factors of the individual recieving it. The options include partial and full removal of thyroid gland, antithyroid drug therapy, and radioiodine therapy (franklyn).

There are varying ideas on which is the best management of Graves' disease.

Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

• Hyperthyroidism
• Hyperparathyroidism
• Tyroid cancer
• Myasthenia gravis
• Psychological disorders (anxiety, panic attacks, or mood disorders)
  
• Atrial Fibrilation
• Congestive Heart Failure

Pathology, Fukushima, DD

Case Reports/ Case Studies

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Related Articles (from Pubmed)

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Resources

National Graves' Disease Foundation

      http://www.ngdf.org/

American Thyroid Association (ATA)

       http://thyroid.org/

American Association of Clinical Endocrinologists (AACE)

       http://www.aace.com/

The Endocrine Society

       http://www.endo-society.org/

The Hormone Foundation

        http://www.hormone.org/

American Autoimmune Related Diseases Associations (AARDA)

         http://www.aarda.org/

References

see adding references tutorial.