July month is for Graves' Disease awareness, which is a condition with hyperthyroidism and thyrotoxicosis. Thyrotoxicosis is a clinical syndrome due to overproduction of thyroid hormones.
What is the mechanism behind Graves' Disease ? ( pathogenesis)
It's an autoimmune condition with presence of IgG autoantibodies against TSH receptor inside the thyroid tissue ,which inturn leads to stimulation of thyroid hormone synthesis.Thyroid gland enlarges due to increased expression of fibroblast growth factor. There is a cross reactivity between thyroid antigens and antigens present in orbit and extra orbital tissue.
Aetiology unknown, run in families, associated with certain genes .Other factors like stress, smoking, steroids, dietary iodine intake, Lithium, female gender. Graves disease also associated with Type 1 diabetes, vitiligo, and other conditions like Addison's disease.
What are the manifestations or characteristics ?
Diffuse goitre, eye and skin involvement which are known as opthalmopathy and dermatopathy. More in females, complications more among smokers.
Eye complications in Graves' Disease manifests as eye swelling, eye irritation, foreign body sensation ,eye watering ,there will be feeling of pressure sensation behind the eyes due to deposition of glycosaminoglycans and lymphocytic infiltration of orbital and retro orbital tissue. Sometimes corneal ulceration may occur as complete eye closure may not be possible while sleeping. Double vision, decrease vision, colour vision due to pressure or stretching of optic nerve which is an emergency situation. So many eye signs are there.
Skin manifestations are raised, edematous, pink nodular lesions above the shin.
How to diagnose
Clinical history, symptoms of hyperthyroidism like weight loss, anxiety, irritability, fatigue, breathlessness, heat intolerance, sweating, hairloss, brittle nails, increased appetite, menstrual irregularities and signs like increased heart rate, tremor, warm moist skin among others.
Lab investigation
Thyroid function test
Test for antibodies to TSH receptor.
Radiological investigation in case of opthalmopathy ( eye complications)
Management
Antithyroid medication, other medications to treat symptoms due to thyroid hormone excess, Radioiodine treatment ( not given in pregnancy, lactation, children), follow up needed. TSH level needs to be checked annually.
Treatment of orbital complications to be done. Relapse and Remission can occur in Graves' Disease.
Surgery for those whom Radioiodine is contraindicated, cosmetic, not controlled with antithyroid medication, eye complications, associated carcinoma , compression symptoms in the neck like difficulty in swallowing, breathing difficulties. Patient needs to be euthyroid before surgery to prevent complications like thyroid storm.
To summarise dysfunction of thyroid is common, few may be autoimmune. When a patient has thyroid swelling, features of hyperthyroidism, they need medical evaluation, follow up. Since smoking is associated with doubling of complications in Graves disease , awareness is necessary.
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