Graves disease is the autoimmune form of hyperthyroidism, and its antibodies stimulate the thyroid’s TSH receptor; Graves disease: epidemiology, pathogenesis and ophthalmopathy explains how. Graves disease adds signs of its own in the eyes, the skin and the fingers. Some signs therefore fit any thyrotoxicosis, while the eye and skin signs point to Graves disease specifically.
The general signs of too much thyroid hormone
What does the body look like when it runs fast? The clinical picture of Graves disease is the general picture of thyrotoxicosis plus the features that belong to Graves disease alone. How it shows depends on the level of thyrotoxicosis, on sex and on age.
In elderly patients the signs can be subtle and masked, reduced to weight loss and fatigue. This masked presentation is called apathetic thyrotoxicosis.
Body weight falls even though appetite is increased. This happens because the basal metabolic rate is raised: the body burns energy faster.
The heart and circulation
Next, the heart and blood vessels. The common cardiovascular signs and symptoms of thyrotoxicosis are:
- supraventricular tachycardia and palpitations
- high cardiac output
- widened pulse pressure
- an aortic systolic murmur
- worsening angina
- atrial fibrillation, mostly in patients over 50 years
Bone and calcium
Long-standing disease also reaches the bones. Long-standing thyrotoxicosis can lead to osteopenia. In about 20% of cases it also causes mild hypercalcemia.
The thyroid gland
The gland itself changes too. In Graves disease the thyroid is diffusely enlarged, which fits the earlier point that the gland has no feedback control of its own growth. The goiter is smooth and two or three times normal size. It is firm and has no nodules. A bruit may be heard over the thyroid, because the overactive gland is more vascular.
The eyes
Some eye signs point to thyrotoxicosis in general, others to Graves disease. Lid retraction and a staring appearance are not specific to Graves disease, because lid retraction can be seen in any form of thyrotoxicosis.
Ophthalmopathy is different: it is specific to Graves disease. About one-third of patients with Graves disease have ophthalmopathy. As the earlier note explained, immune infiltration of the orbit causes proptosis, and in severe ophthalmopathy it can cause optic neuropathy.
The skin and fingers
The last organs involved here are the skin and fingers. Thyroid dermopathy can be seen in less than 5% of patients. It is always present in the presence of Graves ophthalmopathy. It is a painless, non-pitting thickening of the skin, and it occurs mostly on the anterior and lateral side of the leg.
Thyroid acropachy is a form of clubbing. It can be seen in less than 1% of patients with Graves disease.
Do these signs stay, fade or come back over the years, and what happens to them once treatment starts?