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?
Now we know that Graves’ disease is an autoimmune disease. It usually has a genetic predisposition. A family history of Graves’ disease or some other autoimmune disease is usually present. Graves’ disease 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.
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.
When Graves’ disease affects the thyroid gland, it causes an overproduction of thyroid hormones, which is medically called hyperthyroidism. Graves’ disease usually causes diffuse enlargement of the thyroid gland, medically known as a goiter.
When Graves’ disease affects the eyes, it causes what is medically known as Graves’ orbitopathy or ophthalmopathy.
When Graves’ Disease affects the skin, we call it Graves’ dermopathy or pretibial myxedema.
Symptoms of Graves’ Disease
The symptoms of Graves’ Disease are usually due to an overactive thyroid, which is medically known as hyperthyroidism.
Common symptoms and signs due to hyperthyroidism are:
- 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.
Rarely, patients can develop extreme hyperthyroidism known as Thyroid Storm. Symptoms include high grade fever, markedly increased sweating, high blood pressure, chest pain, congestive heart failure, palpitations, weakness, disorientation, irritability, confusion and psychosis.
Causes of Thyroid Storm
- Radioactive iodine for overactive thyroid
- Untreated hyperthyroidism for a long time
- Stress, including trauma and infections such as pneumonia
- Heart attack
- Thyroid Surgery for overactive thyroid
- Sudden stopping of anti-thyroid drugs
- Too much thyroid hormone for thyroid hormone replacement
Thyroid storm is a medical emergency and should be treated by an experienced endocrinologist.
Symptoms of Hyperthyroidism in the Elderly
In the elderly, the symptoms of hyperthyroidism are few and less dramatic than what is seen in young individuals. Instead of a hyperkinetic state, there is apathy. That’s why it’s called apathetic hyperthyroidism. It was first described in medical literature by Dr. Lahey in 1931.
The usual symptoms of apathetic hyperthyroidism are depression, weakness and decreased appetite instead of high energy, agitation and increased appetite typically seen in young individuals. Chronic diarrhea and atrial fibrillation are other manifestations of apathetic hyperthyroidism in the elderly. Eye symptoms of Graves’ disease are usually absent.
The diagnosis of apathetic hyperthyroidism in the elderly is often missed because a family physician typically does not think beyond the usual mindset of a symptom-related approach. In this case, usually the physician may think of cancer, heart disease and endogenous depression, especially if you live in the USA. Often, a patient sees a lot of specialists such as a psychiatrist, oncologist, cardiologist and gastroenterologist. Typically, a number of invasive and expensive tests are done, especially if you have good insurance. What often is not done is a simple blood test for thyroid and a referral to an endocrinologist. In this way, a lot of precious time gets wasted and the patient suffers unnecessarily. Sad but true!
You cannot entirely blame the family physician or other specialists who simply practice what they were trained to do. In addition, they practice defensive medicine to protect themselves against medical lawsuits in the USA. Undiagnosed heart disease and cancer are the two most common causes for medical lawsuits in the USA.
Graves‘ Orbitopathy or Ophthalmopathy
When Graves’ disease affects the eyes, it is called Graves’ orbitopathy or ophthalmopathy.
Symptoms include bulging of eyes, which is medically called proptosis or exophthalmos. Usually, bulging of eyes occurs in both eyes symmetrically. Sometimes, the bulging may be more pronounced on one side than the other, in which case you should have an ultrasound, CT scan or MRI scan of the orbits to exclude any tumor behind the eye.
Often, there is a feeling of irritation, a feeling of a foreign body and excessive tearing. There may be redness of the eyes due to conjunctivitis, as well as blurry vision and sensitivity to light due to corneal ulceration. Some patients may feel pressure behind the eyes. Occasionally, there may be severe pain, which is an emergency for which you should call your physician immediately or go to the Emergency Room at a hospital.
Sometimes, you may start to see double, usually in the upward gaze, but double vision can be in any direction. Initially, double vision is intermittent, but later it can be present all the time. Rarely, Graves’ orbitopathy can lead to decreased vision and even blindness if left untreated.
Symptoms of eye disease usually develop concurrently with symptoms of hyperthyroidism. However, eye disease may precede or develop after the symptoms of hyperthyroidism.
Graves‘ Dermopathy/Pretibial Myxedema
Rarely, patients with Graves’ disease may also experience a peculiar thickening of skin on the shins. It is best described as an orange peel. This is known as Graves’ dermopathy or pretibial myxedema.
Graves’ Disease Without Any Symptoms
Rarely, patients with Graves’ disease do not have any symptoms. 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. This does not require any drug treatment, radioactive iodine or surgery. However, it does require treatment of the underlying autoimmune disorder, as is outlined later in this book.
Treatment of Graves’ Disease
Treatment of Graves’ disease includes:
1. Gluten-free diet.
2. Counselling to alleviate fear, worries and anxiety.
3. A good dose of Vitamin D. Please refer to my book, “Power of Vitamin D.”
4. Drugs vs. Radioactive Iodine vs. Surgery
Drugs vs Radioactive Iodine vs Surgery:
Treatment options for Graves’ disease include:
1. Anti-thyroid drugs (Tapazole or PTU) for 18 – 24 months or even longer.
2. Anti-thyroid drugs (Tapazole or PTU) in the acute phase followed by administration of radioactive iodine.
3. Surgery, which is needed only in rare situations, when the above two choices are not feasible.
Your doctor (an endocrinologist) should discuss pros and cons of each treatment option with you.
Below is an outline of pros and cons of each treatment option.
These drugs are used to control symptoms of hyperthyroidism.
Tapazole (methimazole) and PTU (propylthiouracil) are the two anti-thyroid drugs available in the US.
Treatment with an anti-thyroid drug for a period of 18-24 months can result in about a 50% cure rate once the drug is stopped.
In others, hyperthyroidism can recur upon discontinuation of the drug.
These anti-thyroid drugs are generally well tolerated, but occasionally side-effects may develop which include skin rash, liver toxicity and suppression of bone marrow resulting in a decrease in the number of white blood cells, predisposing the patient to serious life-threatening infections.
Therefore, these drugs should be prescribed only by endocrinologists, who are experienced in using these drugs.
Radioactive iodine is used in the treatment of Graves’ disease, thyroid cancer and occasionally, a multinodular goiter.
In the treatment of Graves’ disease, radioactive iodine is used in very small amounts (usually about 9 – 12 mCi) However, this dose is enough to pretty much kill the thyroid gland.
Radioactive iodine usually takes about 2-3 months to be effective.
Most patients become hypothyroid, usually within a few months of treatment and then require replacement with thyroid hormone in the form of pills, for the rest of their life.
In most people, one dose of radioactive iodine does the job, but in some patients, more than one dose is required to control hyperthyroidism.
Radioactive iodine must be used cautiously in patients who also have Graves eye disease, as there is a potential to aggravate the eye condition. This problem can be avoided by giving steroids such as Prednisone before and after radioactive iodine treatment.
Radioactive iodine must not be used in pregnant patients.
Excerpts from my book,”Graves’ Disease And Hyperthyroidism”
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