Grave's disease

Question 1

what is it?

Answer 1

an autoimmune disorder

antibodies to TSH receptor, thyroid peroxisomes and thyroglobulin

Question 2

Anti TSH receptor antibodies

Answer 2

Thyroid stimulating immunoglobulin – Relatively specific (unlike peroxisome and thyroglobulin abs)
Thyroid growth stimulating immunoglobulin
TSH binding inhibitor immunoglobulins – may explain episodes of hypofunction

Question 3

who gets it?

Answer 3

10F:1M
20-40 yrs old
female’s lifetime risk is roughly 1%
smoking is an important risk factor

Question 4

how does it present?

Answer 4

triad of features

Hyperthyroidism with diffuse enlargement of the thyroid
Eye changes (exophthalmos) - The eye changes result from fibroblasts etc expressing TSH receptors
Pretibial myxoedema. – a rare clinical sign of Graves’ disease, an autoimmune thyroid disease which results in hyperthyroidism

Question 5

thyroid hormone results

Answer 5

decreased TSH

increased fT4/3 - cardinal abnormalites

Question 6

other abnormalities seen in laboratory test

Answer 6

Hypercalcaemia and ↑Alkaline phosphatase
o Reflective of increased bone turnover
o Graves’ associated with osteoporosis

Leucopenia (↓white cell count)
o Often mild and related to the disease rather than treatment (ATD-induced agranulocytosis)

TSH receptor antibody (TRAb)
o No need to image thyroid gland if raised titre found

Anti-TPO antibodies (70-80%)

Question 7

what is a thyroid storm?

Answer 7

Medical emergency, so… A,B,C!
Severe hyperthyroidism
Respiratory and cardiac collapse
Hyperthermia
Exaggerated reflexes
May require mechanical ventilation
Typically seen in hyperthyroid patients with an acute infection/illness or recent thyroid surgery

Question 8

how is it managed?

Answer 8

Lugol’s Iodine
Glucocorticoids
PTU
β-blockers
fluids
monitoring