Graves’ disease

Published on 02/04/2015 by admin

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Last modified 02/04/2015

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136 Graves’ disease

Instruction

Look at this patient.

Determine this patient’s thyroid status.

Salient features

• Patient is fidgety and restless.

History

• Easy irritability, nervousness, insomnia

• Fatigue

• Weight loss with increased appetite

• Frequent defaecation

• Oligomenorrhoea

• Dislike for hot weather, heat intolerance, excessive sweating

• Palpitations, dyspnoea

• Family history of thyroid disease

• Proximal muscle weakness, muscle atrophy, periodic paralysis (particularly in patients of Oriental extraction).

Examination

Proceed as follows: Hands:

• While shaking hands with the patient note the warm sweaty palms.

• Look for tremor, thyroid acropachy (Fig. 136.1; a hypermetabolic state leading to axial bone destruction; do not confuse it with clubbing, which is usually painless), onycholysis (Plummer’s nails), vitiligo and palmar erythema.

• Check pulse for tachycardia or the irregularly irregular pulse of atrial fibrillation.

image

Fig. 136.1 Rare thyroid acropachy.

(With permission of Kronenberg et al. 2008.)

Eyes:

• Comment on proptosis (after looking at the eyes from behind and above)

• Check for lid lag

• Check for scars of previous tarsorraphy.

Neck:

• Mention previous thyroidectomy scar if present

• Examine the neck for goitre and auscultate over the gland.

Chest:

• Gynaecomastia can occur in men as a result of increased oestrogen production.

• Examine the cardiovascular system: sinus tachycardia, widened pulse pressure, loud first heart sound, third heart sound, systolic murmur, atrial fibrillation.

Lower limbs:

• Examine the shins for pretibial myxoedema (bilateral pinkish, brown dermal plaques; see Fig. 139.1).

• Test for proximal myopathy with hyper-reflexia.

Tell the examiner:

• that you would like to check for thyroid-stimulating antibodies (TsAb): near 100% detection rate in patients with Graves’ disease.

Diagnosis

This patient has tremor, proptosis and lid lag (lesions) caused by autoimmune Graves’ disease (aetiology), and is in fast atrial fibrillation and hyperthyroid (functional status).

Questions

How would you confirm the diagnosis in this patient?

Serum thyroxine (T4), serum thyroid-stimulating hormone (TSH; thyrotrophin) levels and thyroid autoantibodies.

What are the causes of hyperthyroidism?

• Primary: Graves’ disease, toxic nodule, multinodular goitre, Hashimato’s thyroiditis, iodine-induced, excess thyroid hormone replacement, postpartum thyroiditis

• Secondary: pituitary or excess TSH hypersecretion, hydatidiform moles, struma ovarii, factitious.

What are the components of Graves’ disease?

Hyperthyroidism with goitre, eye changes (see Fig. 138.1) and pretibial myxoedema: they run independent courses.

Advanced-level questions

What happens to radioactive iodine uptake in Graves’ disease?

Radioactive iodine uptake increases in Graves’ disease.

Which is the best laboratory test to diagnose hyperthyroidism?

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