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Graves Disease and Graves Ophthalmopathy | Signs, Symptoms, Diagnosis and Treatment

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Lesson on Graves’ Disease and Graves’ Ophthalmopathy: Signs and Symptoms, Diagnosis and Treatment. Graves’ disease is an autoimmune disorder caused by production of stimulatory autoantibodies to TSH receptors that lead to excessive production and release of thyroid hormones T4 and T3. High levels of T4 and T3 lead to HYPERthyroidism with characteristic HYPERthyroidism signs and symptoms including tachycardia, insomnia, anxiety and agitation, increased bowel movements and weight loss. Graves’ disease most often affects women in their 30s and 40s and is associated with other autoimmune disorders. Graves’ disease is associated with Graves’ opthalmopathy, an extra-ocular muscle disorder caused by autoattack on retro-orbital fibroblasts that leads to characteristic Graves’ signs and symptoms including proptosis, exophthalmos, and periorbital edema, and in significant cases, corneal abrasions and sight loss.

Hey everyone in this list want to talk about graves disease where i talk about what graves disease is what are some of the signs and symptoms of grey’s aziz how do we diagnose it and then what do we use to treat it so graves disease is an autoimmune disorder caused by stimulatory auto antibodies to the tsh receptor so the thyroid stimulating hormone receptor

That leads to hyper thyroidism so again graves disease is an autoimmune disorder that causes stimulatory auto antibodies to the tsh receptor that leads to hyper thyroidism so just as a brief background as to how the thyroid functions normally normally it all starts in the hypothalamus hypothalamus releases trh or thyrotropin-releasing hormone which acts on

The anterior pituitary to stimulate the release of tsh tsh then travels to the thyroid gland to stimulate the thyroid gland to release t4 and t3 and this t4 and t3 actually has a negative feedback regulation on the hypothalamus and anterior pituitary suppressing both trh and tsh so with graves disease if we’re getting a production of stimulatory auto antibodies

Antibodies that are targeting a person’s own tsh receptors in the thyroid gland so these are the antibodies they target the tsh receptors on a thyroid cell in the thyroid gland stimulates that thyroid cell to actually produce and release t4 and t3 that t4 and t3 would actually negatively regulate both the hypothalamus and the anterior pituitary gland leading to a

Suppressed level of tsh so in graves disease you can imagine we’re getting high levels of t4 and t3 and low levels of tsh because this negative feedback regulation so we’re going to talk more about this when we talk about how we actually diagnose graves disease but i just wanted to show you the mechanism by which that can happen graves disease is the most common

Cause of thyrotoxicosis thyrotoxicosis is this condition where in we have very high levels of thyroid hormones leading to specific consequences we’re going to talk about more about thyrotoxicosis in a future lesson graves disease can occur at any age but generally peaks between the ages of 30 and 40 years in females outnumber males 7 to 1 so graves disease is a

Predominantly female disease and about 1.5 to 2 percent of women will get graves disease at some point in their lives graci sees itself has a familial predisposition there is an association with genes hla b8 and hlad r3 and there’s also associations with other autoimmune disorders so the signs and symptoms of graves disease depend on the effects of high levels

Of t4 and t3 this leads to hyperthyroidism so graves disease we see signs and symptoms of hyperthyroidism some of those symptoms include anxiety and agitation heat intolerance sweating or excessive sweating heart palpitations weight loss increased bowel movements generally increased frequency of diarrhea insomnia so difficulty sleeping tachycardia so high rate

Of our high heart rate this high heart rate can lead to onset of arrhythmias like atrial fibrillation there can be tremors palmar erythema so a reddening the palms of the hands hyperreflexia and proximal weakness so the signs and symptoms of grave disease are the signs and symptoms of hyperthyroidism hyperthyroidism again is due to the effects of high levels of

T4 and t3 t4 and t3 regulate of a wide variety of things in our body and you can remember it by the m’s movement mentation and metabolism movement so increased movement so hyperthyroidism you can think of increased movement agitation you can think of tremors you can think of increased bowel movements things are moving quickly meditation is that anxiety component

And the other one is metabolism and the increased metabolism you can think of the weight loss you can think of having a high level of energy insomnia those types of things so generally great disease again is hyperthyroidism we’re gonna see signs and symptoms of hyperthyroidism grizzly’s also has some specific signs and symptoms with regards to its etiology some

Of the more specific signs and symptoms of graves disease include a thyroid corder thyroid gorder is generally diffuse and it’s described as rubbery and there is no lymph adenopathy with the thyroid gorder there’s also what we call proptosis and exophthalmos kind of a bulging of the eyes in these patients we’re gonna talk about more about why this happens in the

Next slide there’s also conjunctival injection periorbital edema so a swelling around the eyes pretibial mix edema acro patchy which is just a distal phalangeal clubbing so all of these symptoms are all these signs are more specific to graves disease as a so just a general hyperthyroidism some of the other symptoms include diplopia so a double vision due to some

Of these changes with regards to the eyes and people with graves disease and also corneal abrasions just because with the proptosis and exophthalmos the eyes generally are bulging out and they end up becoming dried out and can be easily easily embraced or easily have abrasions of the cornea and that leads me into our next topic which is graves ophthalmopathy graves

Ophthalmopathy and graves disease aren’t exactly the same thing some individuals can have gray’s up the mapa the– without having the signs of hyperthyroidism but they may get those signs and symptoms later some individuals with graves disease will have the signs and symptoms of hyperthyroidism without the grays optima path ii but they generally have the same cause

It’s caused by an auto attack with those auto antibodies to retro orbital fibroblasts so those auto antibodies in graves disease can stimulate the thyroid gland but they can also cause damage to retro orbital fibroblasts which lead to extra ocular muscle involvement so again i want you to kind of separate these two entities out grayza optimally in graves disease

Are not exactly the same thing but they are part of the same kind of entity but again some people can have graves off them up feet without having the signs and symptoms of hyperthyroidism some people can have the hyperthyroidism without having this grey’s off the mathy and some people have both and we can remember the signs and symptoms of gray’s ophthalmopathy with

The mnemonic elle specs l stands for lid leg or lid retraction s stands for soft tissue this soft tissue is the periorbital edema conjunctival injection and key moses some of those signs and symptoms i talked about in the previous slide so those signs and symptoms are really related to the graves ophthalmopathy part of it there’s also the proptosis the extraocular

Component so that diplopia so they start having the double vision corneal abrasions for the c and s for sight loss and they are laid out in a way that the earlier signs and symptoms of graves ophthalmopathy are the starting with l and then the later signs and symptoms are later on in the mnemonic so corneal abrasions and sight loss are later manifestations of

Graves ophthalmopathy as the condition gets worse and worse eyes become begin to prop toasts or they have ox f thymus which lead to drawing of the eyes corneal abrasions and sometimes eventually sight loss so how do we make the diagnosis of graves disease diagnosis begins by looking at tsh and t4 levels in graves disease as we mentioned before tsh levels are low

Because of that negative feedback inhibition by those high levels of t4 and again we see increased free t4 levels but this doesn’t necessarily tell us that it is graves disease we need something else some of the other components of graves disease that aren’t as specific either are having a positive thyroid globin stimulating immunoglobulin having anti proc cities

Being elevated but what i really wanted to remember is this radio iodine uptake test this ryu test so when we see low t8t low tsh levels and increased free t4 levels we can start thinking about hyperthyroidism but to distinguish it between other causes of hyperthyroidism like toxic adenoma x’ we can use a ryu test so the ryu tests increased iodine-131 uptake er i

131 uptake and it is a homogenious uptake so if we take a look at a ryu scan we can see here this is a normal thyroid with normal uptake of i-131 and in graves disease you can see this is quite increased and it is homogeneous because the antibodies have access and come into contact with the entire thyroid gland and this can lead to a homogeneous increased uptake

Of ai 131 and this is distinguished between other causes or other thyroid diseases like toxic multinodular goiter with multiple hot spots and toxic adenoma where there’s one hot spot that’s causing some hyperthyroidism so graves ease again increased i 131 uptake that is homogenius we see low tsh levels and increased 3 t4 levels and it’s all due to stimulatory

Auto antibodies to the tsh receptor and one more quick note i want to discuss about diagnosing graves disease is biotin and you may be thinking why am i talking about biotin here biotin supplementation has become popular in recent years and it’s used for skin and nails and those types of things but what it’s been found is that biotin supplementation can actually

Interfere with measurements of tsh in t4 and it has actually been found that individuals that actually take biotin supplements can actually have falsely low tsh measurements and or falsely high t 4 levels so it looks like they’re actually have hyperthyroidism it actually looks like they might have graves disease and some individuals can actually even be treated

For great disease but they actually don’t have it it’s really just because they’re actually taking a biotin supplementation so it’s always important to ask patients if they’re taking biotin supplements because it can or it may actually interfere with ts eighty-four measurements once we made the diagnosis of graves disease how do we treat it treatment is by sion

Amides diam ides include methimazole which is the first-line treatment for a disease or propylthiouracil ptu they both inhibit peroxidase catalyze reactions to inhibit thyroid hormone synthesis and ptu has a little extra component where it inhibits peripheral the i don vi domination of t4 to t3 and generally patients continue treatment until remission of graves

Disease both of these medications have side effects but ptu has specific side effects that we want to avoid and makes us weary of using pt you some of the side effects include hepatitis agranulocytosis fever and rash and the two first two hepatitis and agranulocytosis are what we really worry about and this is why we generally want to start with methimazole and

Only use ptu in certain circumstances i’ll tell you when we use pt you other treatments for grey disease include beta blockers for symptomatic relief can do thyroid ablation in certain circumstances using i 131 and in even severe cases we may use subtotal or total thyroidectomies so some special circumstances or special considerations with treatment pregnancy is

The special consideration i want you to remember and this is when we want to use ptu we want to use pt you in the first trimester as methimazole has been shown to cause an embryo ëthey in pregnancy in the first trimester we can then switch over to methimazole in the second and third trimester so pt in the first trimester metha ms on the second and third trimester

For optimal t there’s a few different considerations we can employ one is smoking cessation another one is preventing drying of the eye so we can that with proptosis an x-up thalamus the eyes are you know predisposed to excessive drawing also the smoking can also have some effects on bulging eyes we may also end up using high-dose prednisone and in severe cases we

May have to do orbital decompression so anyways guys i hope you found this lesson helpful this was a lesson on graves disease if you found this lesson helpful please like and subscribe for more lessons like this one and as always thank you so much for watching and i’ll see you next time

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Graves Disease and Graves Ophthalmopathy | Signs, Symptoms, Diagnosis and Treatment By JJ Medicine