Grave's disease

Condition

• Grave's disease

Definition

• Grave's disease named after Rober J Graves, is an autoimmune disease characterized by hyperthyroidism due to circulating autoantibodies.

History

• Female: Male ratio 5-10: 1
• Peak onset 40-60 years
• Diffuse, usually symmetrical goitre
• Graves ophthalmopahty
• Associated with other autoimmune diseases 
• The most frequent symptoms of thyrotoxicosis are nervousness, heat intolerance, palpitations, fatigue and weight loss (weight gain occurs in 10% people)

Examination

• Agitation 
• Sinus tachycardia 
• Fine tremor 
• Hyper-reflexia
• Graves ophthalmopathy 
• Pretibial myxodema 1-2 %
• thyroid acropachy (digital clubbing < 1%)

Investigation

• Blood test: Thyroid function test, TSH receptor Ab positive, TPO Ab often positive
• Radionuclide thyroid scan: normal or elevated diffuse uptake pattern

Management

• Oral medications
• Carbimazole 
• Propylthiouracil 
• Agranulocytosis is a rare but life threatening complication of both antithyroid drugs with an incidence of 0.2-0.5%. Most commonly happen in the first 3 months, but can happen at any time
• Severe hepatocellular inury occurs with propylthiouracil in 0.1% of patients treated with the drug, and approximately 10% of these patients develop liver failure resulting in either a liver transplant or death
• 4 weeks following initiation of therapy, clinical review with repeat thyroid function tests should be undertaken to avoid hypothyroidism
• Beta blockers may be used for symptom control. A nondihydropyridine calcium channel blocker (e.g. verapamil) can be used to control heart rate when beta blockers are not tolerated

References:

• http://www.racgp.org.au/afp/2012/august/evaluating-and-managing-patients-with-thyrotoxicosis/