GRAVE’S DISEASE

 Grave’s disease is an autoimmune thyroid disease

 The disease is characterized by a triad of three clinical
findings:
 HYPERTHYROIDISM
 OPHTHALMOPATHY
 DIFFUSE THYROID ENLARGEMENT

 The most common manifestation is thyrotoxicosis with or

without a diffuse goitre
PATHOPHYSIOLOGY

 The Grave’s thyrotoxicosis results from production of

IgG antibodies directed against the TSH receptor on
the thyroid follicular cell, which stimulate thyroid
hormone production and proliferation of follicular cells
leading to goitre in majority of patients.
 These antibodies are termed TSI and can be detected
in the serum of patients with grave’s disease.
THYROTOXICOSIS

 It is a hypermetabolic state caused by elevated

circulating levels of T3 & T4
 This may be primary or secondary
 PRIMARY THYROXICOSIS: Hyperthyroidism arising from
an intrinsic thyroid abnormality
 SECONDARY THYROTOXICOSIS: Hyperthyroidism arising
from processes outside of the thyroid, such as a TSH
secreting pituitary tumour
CLINICAL FEATURES

Signs Symptoms
 Tiredness
 Tachycardia  Emotional lability
 Hot/moist palms  Heat intolerance
 Exophthalmos  Weight loss
 Eyelid retraction  Excessive appetite
 Agitation  Palpitations
 Thyroid goitre
THYROTOXICOSIS IN
PREGNANCY
 The coexistence of pregnancy and thyrotoxicosis is
unusual, as anovulatory cycles are common in
thyrotoxic patients.
 The most common cause is gestational transient
thyrotoxicosis(GTT) which occurs from the stimulatory
action of HcG on the TSH receptor.
TREATMENT
 Antithyroid drugs commonly used are CARBIMAZOLE
and PROPYLTHIOURACIL
 Beta Adrenergic blockers such as PROPRANOLOL and
NADOLOL are used to block CVS effects of the
elevated T4.
NEONATAL THYROTOXICOSIS

 It occurs in babies born to hyper thyroid mothers or to

euthyroid mother who had thyrotoxicosis
 High TSH Rab titres are present in both mother and child
because these antibodies can cross the placental
barrier
 The hyper thyroidism gradually subsides in 3 to 4 weeks
time as these antibody titres fall in the baby’s serum
DIAGNOSIS

 Suppressed TSH and an elevation of T3&T4

 Thyroid radio iodine(I131) uptake is raised in graves
disease
 The presence of raised serum concentrations of
thyroperoxidase (TPO) antibodies indicates an auto
immune thyroid disorder and a raised TSI value
indicates graves disease
SURGERY

 Patients should be rendered euthyroid with antithyroid

drugs before operation
 Potassium iodide, 60mg TID orally, is often added for 2
weeks before surgery to inhibit thyroid hormone release
and reduce the size, vascularity of the gland, makind
the surgery easier
 Subtotal thyroidectomy is done in which a portion of
one lobe of thyroid is left insitu, with the aim of
rendering the patient euthyroid postoperatively.
 While complications of surgery are rare and 80% of
patients are euthyroin and 15% are permanently
hypothyroid and 5% remain thyrotoxic.
 That is why endocrine surgeons opt to perform near
total thyroidectomy.
POSTOPERATIVE
COMPLICATIONS
 Hemorrhage
 Recurrent laryngeal nerve paralysis
 Thyroid insufficiency
 Thyrotoxic crisis(storm)
 Parathyroid insufficiency
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