Graves disease is named after an eminent, nineteenth century Irish surgeon, Robert James Graves, who first described the association of eye disease with an enlarged thyroid gland.
What is Graves’ Disease?
Graves’ disease is an autoimmune disease. Simply put, your immune system goes haywire. Then, it starts to attack your thyroid gland. In addition, it may attack your eyes and rarely, skin. Graves’ disease affects the thyroid gland in about 90% of cases, eyes in about 25-50% of cases, and skin in about 1-4 % of cases.
Graves disease usually has a genetic predisposition for autoimmune disorders. For example, a family member may have asthma, Type 1 diabetes or Hashimoto’s thyroiditis or Graves disease. It affects females much more commonly than males, with a ratio of about 6:1. It usually starts in young age, but can happen at any age. Onset is usually insidious, but rarely it can be rather acute.
When it affects the thyroid gland, it causes an overproduction of thyroid hormones, which is medically called hyperthyroidism. It usually causes diffuse enlargement of the thyroid gland, medically known as a goiter.
If it affects the eyes, it causes what is medically known as Graves’ orbitopathy or ophthalmopathy.
Rarely, it may affect the skin, we call it Graves’ dermopathy or pretibial myxedema.
Symptoms of Graves’ Disease
- Weight loss despite eating a lot
- Palpitations (rapid heart beat). Sometimes, irregular rapid heart beat, known as atrial fibrillation
- Feeling hot all the time when other people feel comfortable
- Excessive perspiration
- Diffuse enlargement of the thyroid gland, called diffuse goiter
- Too much energy followed by exhaustion
- Shortness of breath
- High blood pressure, especially systolic blood pressure
- Chest pain
- Muscle weakness
- Weakening of bone strength, known as osteopenia or osteoporosis
- High calcium in the blood
- In women, hyperthyroidism can also lead to less frequent, scanty menses and sometimes, even complete lack of menses.
- In men, hyperthyroidism can cause enlargement of breast tissue, medically known as gynecomastia.
Graves’ Disease Without Any Symptoms
Rarely, patients with Graves’ disease do not have any symptoms. But they get diagnosed with Graves disease because their physician does a battery of laboratory tests including thyroid antibodies. I like to consider this condition an early stage of Graves disease. For this reason, it does not require any drug treatment, radioactive iodine or surgery. However, it does require treatment of the underlying autoimmune disorder which includes stress management, diet and high dose of vitamin D, as outlined in Treatment of Graves’ disease
How Do You Diagnose Graves Disease?
An experienced endocrinologist puts all the clinical features of a patient into perspective. In this way, he can readily make a clinical diagnosis of Graves’ disease. Often, the endocrinologist will order a blood test for thyroid antibodies to confirm his clinical impression.
Thyroid Antibody Tests:
- TPO (Thyroid PerOxidase) antibody.
- Tg (ThyroGlobulin) antibody.
- Thyroid Stimulating Immunoglobulin (TSI).
- Thyrotropin Receptor Antibody (TRAB).
Blood tests for TPO and Tg antibodies are easily available. Additionally, these tests are cheap. In the right clinical setting, these two antibody tests are sufficient to confirm the diagnosis of Graves’ disease.
Specific Test For Graves’ Disease:
Thyroid Stimulating Immunoglobulin (TSI) is the most specific test for Graves’ disease. TRAB is another test but is less specific than TSI. Both tests are more expensive, less commonly done and may not be readily available.
Radioiodine Test of Thyroid
Rarely, the endocrinologist will resort to a special test called radioiodine uptake and scan of thyroid, especially to differentiate Graves’ hyperthyroidism from Subacute thyroiditis and Painless thyroiditis. Thyroid radioiodine uptakes are typically high in Graves’ hyperthyroidism, but very low in Subacute thyroiditis and Painless thyroiditis.
Proper Interpretation Of Radioiodine Uptake and Scan
The results of the thyroid radioiodine uptake and scan should be interpreted by an endocrinologist in the context of the overall clinical picture of the patient. Sometimes, an overzealous radiologist may over-interpret the test, which can lead to misdiagnosis. For example, a radiologist may suggest that the patient has hypothyroidism (Underactive Thyroid), based upon low uptake values of radioiodine, which are not only seen in hypothyroidism, but also typically seen in cases of hyperthyroidism (overactive thyroid) due to Subacute thyroiditis, post-partum thyroiditis as well as Painless thyroiditis. A family physician may follow the radiologist’s advice and put this patient on thyroid hormone replacement, which is like adding fuel to the fire. Then, the patient may end up with a serious medical emergency. I have encountered these kinds of messed up cases.