GRAVES’ DISEASE AND THYROTOXICOSIS : SYMPTOMS AND SIGNS

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Graves’ Disease and the Manifestations of Thyrotoxicosis

DeGroot LJ.

ncbi.nlm.nih.gov/books/NBK2...

SYMPTOMS AND SIGNS OF GRAVES’ DISEASE AND THYROTOXICOSIS

In patients with Graves' disease, the ocular changes, lymphoid hyperplasia, localized abnormalities of skin and connective tissue (e.g., acropachy) and the goiter itself represent parts of the autoimmune syndrome. The remainder of the changes appear to be entirely attributable to an excess of thyroid hormone. Certain systems or organs (e.g., the muscles and cardiovascular system) play paramount roles in the disease, but as far as can be determined, these changes are all fundamentally related to and dependent on the excessive serum concentration of thyroid hormones.

Often the presenting symptoms are weight loss, weakness, dyspnea, palpitations, increased thirst or appetite, hyperdefecation, irritability, profuse sweating, sensitivity to heat or increased tolerance to cold, or tremor. Occasionally, prominence of the eyes or diplopia is the apparent symptom, and goiter may long antedate all other manifestations. Often a relative or friend notices eye signs, goiter, or nervous phenomena before the patient is conscious of any departure from his or her usual status. This asymptomatic phase of thyrotoxicosis is more commonly found in men and children. The excess of thyroid hormone produces an intoxication that in some persons takes the form of exhilaration. They may feel not only healthy but healthier than usual at a time when they are displaying unmistakable objective evidence of thyrotoxicosis. In older patients particularly, the symptom or symptoms may point to the heart more than to any other part of the body, "thyrotoxicosis masquerading as heart disease."

The habitus in Graves' disease shows nothing characteristic. In childhood, those afflicted are tall for their age. This association is an effect of the disease, not an etiologically related variable.

The nutritional state varies greatly. Sometimes the patient is severely emaciated, but on average the weight loss is 5 - 20 lbs. Infrequently, perhaps in 1 out of 10 instances, the patient actually gains weight while thyrotoxic.

The face may may instantly provide the diagnosis. An expression of fright or extreme anxiousness is common, largely because of the peculiar eye signs that may be present. Marked flushing is often noted. A drawn or sunken appearance may result from emaciation or dehydration. It is possible, especially in older patients, to find a considerable degree of thyrotoxicosis without any distinguishing evidence in the facies.

A change in reaction to external temperature is a very classic symptom. The development of a preference for cold weather, of a desire for less clothing and less bed covering, and of decreased ability to tolerate hot weather is highly suggestive of hyperthyroidism.

The tongue tends to be red and smooth; it may also exhibit a definite tremor. The tonsils, if present, are usually rather large, as is the postpharyngeal lymphoid tissue.

The neck is usually conspicuous due to the goiter. It is possible, although rare, for thyrotoxicosis to exist without a visible or palpable goiter. We note reports in the literature that up to a quarter of patients may not have a goiter [272], but this is not our experience. In the neck, the carotids will often be seen to throb violently; this condition may contribute to the anxiety of the patient.

The eye signs characteristic of Graves' disease often constitute the most striking feature (Fig. 10-4 above, Fig. 10-5, Fig. 10-6 below). Prominence of the eyes is the most important sign. A wild or staring expression is often observed. Lag of the lids behind the globes on downward rotation and lag of the globes behind the lids in upward rotation, infrequent blinking, failure to wrinkle the forehead on looking upward, and decreased ability to converge are also cardinal manifestations. Swelling of the lids is a characteristic and frequent eye sign. The bulbar conjunctiva may be edematous (chemosis). The insertions of the medial and lateral rectus muscles are often enlarged, inflamed, and quite obvious . The lacrimal gland can become infiltrated by lymphocytes and enlarged, and may protrude below the orbital boney margin.

For convenience, the ophthalmic phenomena may be grouped as in Table 10-4. A classification of the eye changes and a system of grading of their severity have been adopted by the American Thyroid Association [273] and is given in Chapter 12.

Table 4Ocular Signs and Symptoms in Graves' Disease

Ophthalmic phenomena reflecting thyrotoxicosis per se and apparently resulting from sympathetic overactivity:

Lid reaction

• Wide palpebral aperture (Dalrymple's sign)

• Lid lag (von Graefe's sign)

• Staring or frightened expression

• Infrequent blinking (Stellwag's sign)

• Absence of forehead wrinkling on upward gaze (Joffroy's sign)

Ophthalmic phenomena unique for Graves' disease and caused by specific pathologic changes in the orbit and its contents:

• Inability to keep the eyeballs converged (Mobius' sign)

• Limitation of movement of the eyeballs, especially upward

• Diplopia

• Blurred vision due to inadequate convergence and accommodation

• Swelling of orbital contents and puffiness of the lids

• Chemosis, corneal injection, or ulceration

• Irritation of the eye or pain in the globe

• Exophthalmos (also produces mechanically a wide palpebral fissure)

• Visible and palpable enlargement of the lacrimal glands

• Visible swelling of lateral rectus muscles as they insert into the globe, and injection of the overlying vessels

• Decreased visual acuity due to papilledema, retinal edema, retinal hemorrhages, or optic nerve damage

The eye signs may vary independently of the intensity of the thyrotoxicosis. Although it is true that in most patients with Graves' disease, eye signs, goiter, and symptoms of thyrotoxicosis appear more or less coincidentally, it is also true that in certain cases eye signs may appear long before thyrotoxicosis is evident, or become worse when the thyrotoxicosis is subsiding. Indeed, in some patients, serious exophthalmos may develop at a time when the thyrotoxicosis has been controlled by treatment.

The eye symptoms are extremely distressing. Diplopia is common; decreased visual acuity and other visual disturbances are less common. More frequent are symptoms due to conjunctival or corneal irritation. These symptoms include burning, photophobia, tearing, pain, and a gritty or sandy sensation.

Horner's syndrome on one side is occasionally encountered when the goiter has pressed upon the trunk of the cervical sympathetic chain. This syndrome consists of unilateral enophthalmos, ptosis of the lid, and miosis, as well as decreased sweating on the homolateral face.

[helvella Administrator Thyroid UK]

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