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Grave's Disease

more about Grave's Disease

Diffuse Toxic Goiter

  • This is the most common type of excessive function of the thyroid gland and it is five times more common in females, with a peak occurring in adolescence.  The thyroid gland produces the thyroid hormones triiodothryronine (T3) and thryroxine (T4).  T3 is the more active form.  T4 is also partially converted to T3 when released in the blood stream.  The thyroid hormones regulate metabolism throughout the body.  The pituitary gland releases a hormone called thyroid-stimulating hormone that controls the release of these hormones from the thyroid gland.

  • Enlarged and bulging out eyeballs, lid lag
  • Sensitivity to light and a feeling of "sand in the eyes, double vision, and/or vision loss
  • Neck mass (enlargement of the thyroid gland on the neck)
  • Nervousness, anxiety, emotional lability
  • Heart racing, heart palpitations (atrial fibrillation)
  • Increased blood pressure
  • Heat intolerance
  • Increased sweating
  • Fatigue
  • Weight loss
  • Muscle cramps, weakness
  • Moist, warm skin
  • Hair loss
  • Thinning nails
  • Increased bowel movements

  • It is caused by an autoimmune mechanism.  This is a condition in which an individual's immune system reacts against the body's own tissues, thereby causing diseases.
  • Thyroid-stimulating antibodies (auto-antibodies)

  • Examination:
    1. Ophthalmoplegia
    2. Increased pulse
    3. Irregular pulse
    4. Clubbing/swelling of fingers
    5. Bruit (sound) over thyroid gland
    6. Tremor
  • Laboratory:
    1. Blood tests T3, T4, thyroid resin uptake, and free thyroxine are usually all increased.
    2. 3rd generation TSH is low.
    3. The level of TSI (thyroid stimulating immunoglobulin) is abnormally high
    4. Antimicrosomal or antithyroglobulin antibodies are usually elevated
  • Thyroid scan (radioactive iodine scan) shows diffusely increased uptake (thyroid uptake performed at same time to calculate dose of radioactive iodine that may be needed for treatment)
  • Imaging: MRI of orbits to evaluate extraocular eye muscles

  • Medications:
    1. Propylthiouracil to block thyroid hormone
    2. Propranolol to control heart symptoms and decrease conversion of T4 to T3
    3. Methimazole
    4. Iodine
  • Radioactive Iodine -- swallowed, this stops the hyperthyroidism (stops the overactivity of the thyroid gland).  This can be used for older (nonpregnant) teenagers.  Lifetime thyroid supplementation after treatment is often needed.
  • Thyroid surgery -- can cause Hypothyroidism (low function of thyroid gland)

- Partial thyroidectomy

  • For ophthalmopathy --
    1. No treatment for mild cases, prednisone for more severe cases.
    2. Radiation treatment or surgical decompression may be considered in the case of failure to respond
    3. Artificial tears used if eyes are dry, and lids taped shut during sleep if lid lag keeps them open.
  • For atrial fibrillation:
    1. It usually reverses with treatment for hyperthyroidism. 
    2. Propranolol and Digoxin may be used.  If it persists after treatment for hyperthyroidism, then electrical cardioversion or long term anti-coagulation may be needed.
  • For thyroid storm:
    1. A cooling blanket to reduce high body temperature
    2. Propranolol given intravenously to control rapid heart beat
    3. Propylthiouracil or methimazole every six hours followed by Lugol's solution one hour later.  Corticosteroids (e.g., Solu-Medrol) every six hours. 
    4. Definitive surgical treatment only after thyroid functions have stabilized.
  • Hyperthyroidism in pregnancy:
    1. Propylthiouracil at the lowest dose possible. 
    2. Surgery if propylthiouracil is not sufficient.
  • Dermopathy (skin changes): Topical corticosteroids with nocturnal plastic occlusive dressing.

  • Ophthalmopathy -- lymphocytes (immune fighting cells in the blood) infiltrate the muscles of the eye.  This can result in enlargement of they eyeball, a lid lag, severe dry eyes, compression, and compression of the optic nerve.
  • Atrial fibrillation -- a heart irregularity that increases the risk of stroke
  • Congestive heart failure
  • Thyroid storm -- an extremely severe form of hyperthyroidism that can be life threatening.  Usually accompanied by delirium, Dehydration, rapid heart rate, vomiting, Diarrhea, and high fever.  This is a medical emergency and is life threatening.  If suspected, this condition needs immediate emergency medical treatment.
  • Other complications include decreased libido, impotence, decreased sperm count, enlarged male breasts, and a syndrome called periodic paralysis (sudden paralysis episodes occur)

more about Grave's Disease

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