Friday, July 5, 2024

Graves' Disease.....

Thyroid is an endocrine gland and it is situated in front of the neck. It plays a very crucial role in our daily life by releasing thyroid hormones. Thyroid dysfunction  can occur causing excess ( hyper thyroidism high free T3,T4& low TSH ) or deficiency (low Free T3,T4 & high TSH hypothyroidism).

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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