grave's

Question 1

def grave’s

Answer 1

thyrotoxicosis - syndrome due to excessive amounts of thyroid hormones in bloodstream

Grave’s is a cause of thyrotoxicosis with additional symptoms: goitre, exophthalmos

Question 2

aetiology grave’s

Answer 2

circulating IgG auto-Ab binding to and activating G protein coupled thyrotropin receptors

cause smooth thyroid enlargement and increased hormone production, especially T3

react with orbital autoAg

Question 3

grave’s triggers

Answer 3

stress

infection

childbirth

Question 4

grave’s associations

Answer 4

vitiligo

type 1 dm

addison’s

Question 5

grave’s RF

Answer 5

women

FH

smoking - dose dependent RF, related to higher recurrence rates, RF for Grave’s orbitopathy

autoimmune disease

Question 6

epi grave’s

Answer 6

prevalence 0.5%, 2/3 cases of hyperthyroidism

female>men

40-60yrs (younger if maternal FH)

Question 7

sx grave’s

Answer 7

diarrhoea

weight loss

increased appetite

(if really high get paradoxical weight gain in 10%)

over-active

exercise intolerance, fatigue, muscle weakness

sweats

heat intolerance

palpitations

tremor

irritability

anxiety

labile emotions

oligomenorrhoea +- infertility

reduced libido, gynaecomastia

Rapid-onset malaise, fever, and thyroid pain

polyuria, thirst, generalised itch

Deterioration in blood glucose control and hyperglycaemia in people with diabetes mellitus

Deterioration of co-morbid heart disease, for example in the elderly.

rare: psychosis, chorea, panic, itch, alopecia, urticaria

Question 8

thyroid eye disease

Answer 8

in 25-50% of people with Graves’

main RF - smoking

may not correlate with thyroid disease - can be eu/hyper/hypothyroid

may be 1st presentation of Graves’

can be worsened by treatment - typically with radioiodine

retro-orbital inflammation and lymphocyte infiltration = swelling of orbit

Question 9

sx of thyroid eye disease

Answer 9

eye discomfort

grittiness

increased tear production

photophobia

diplopia

reduced acuity

afferent pupillary defect may mean optic nerve compression

Question 10

signs thyroid eye disease

Answer 10

exophthalmos - protruding eye

proptosis - eyes protrude beyond orbit

conjunctival oedema

corneal ulceration

papilloedema

loss of colour vision

ophthalmoplegia - especially of upward gaze occurs due to muscle swelling and fibrosis

Question 11

ix thyroid eye disease

Answer 11

diagnosis is clinical

CT/MRI of orbits may reveal enlarged eye muscles

Question 12

signs grave’s

Answer 12

pulse fast/irregular - AF or SVT, VT rare

HF

warm moist skin

fine tremor

palmar erythema

thin hair

lid lag - eyelid lags between eyes descent in pursuit

lid retraction - exposure of sclera above iris

goitre - diffusely, symmetrically enlarged w/o nodules

agitation

Pruritus, urticaria, vitiligo, diffuse alopecia.

Muscle wasting, proximal myopathy, hyper-reflexia.

Splenomegaly, lymphadenopathy.

slightly pigmented thickened skin

eye disease: exophthalmos, opthalmoplegia

pretibial myxoedema: oedematous swellings above lateral malleoli

thyroid acropachy: extreme manifestation - clubbing, painful finger and toe swelling and periosteal reaction in limb bones

Question 13

ix grave’s

Answer 13

• reduced TSH
• raised T4 and T3
• mild normocytic anaemia
• mild neutropenia
• high ESR, Ca and LFT
• thyroid Ab
• Isotope scan to detect nodular disease or subacute thyroiditis
• if opthalmopathy - test visual fields, acuity and eye movements