Grave’s

Case Presentation Group 4 Disease

Alexandra Calderón
Katherine Carrero
Kudzai Chimuka
Edward Miller
Leysha Rodriguez
Zoralis Soto
Tatiana Suarez
Betzaida Torres
Kimberly Vázquez
 Demographics

Chief Complaint

History of Present
Illness
Demographics

Patient: Mrs. A.S

Age: 41-year-old
Sex: Female
Race: Afro-Caribbean/ Kittitian
Occupation: Supervisor at Best Buy supermarket
Marital Status: Single
 “I feel tired all the time, have
shaky hands and itching all
Chief complaint over my body”
 History of Present Illness

Onset:
Character:
 Symptoms began on May 2019.
 Constant and intense
 Admitted to the hospital on June 18; as a referral
Aggravating and Alleviating Factors:
of her primary care physician.
 None
 Assessment was done on June 26.
Radiation:
Location:
 No radiation
 Diffuse
Severity:
Duration:
 8/10 on pain scale; worse during the night
 All day
HPI: Associated Symptoms

Negatives:
Productive cough
Positives:
Chest pain
Sweating
Fever
Joint pain

Nausea
Cough

Vomiting
Shortness of breath

Diarrhea
Fatigue

Dizziness
Palpitations

Change in bowel habits or urination
Trouble sleeping

Past Medical History

Family history

Social History
 Past Medical History

Childhood Illnesses: Measles

Immunizations: Does not recall
Adult Illnesses: Chronic Anemia, Chicken Pox in her 30s
Hospitalizations/Surgeries: none
Menarche: 12 years old
LMP: June 17, 2019, describes heavy bleeding since her last pregnancy.
G 4T3 P0A1 L3
Screening: No Papsmear, No Mammogram.
Medications: Trihemic (1pill/day)
Allergies: NKDA
Family History
Social History

Diet and Exercise Unintentional Drug/Alcohol/ Sexual history 1 dog No travel

weight loss in the Recreational
last month Drugs
She eats a balanced No alcohol since 1 partner
diet and does not 2017 Using protection
exercise. Never smoked No history of STDs
No recreational
drugs
 Review of Systems

Physical Examination
 General: excessive sweating, weight loss, palpitations

Review of Skin: itchy

Systems Eyes: wears glasses

Neck: swelling; thyroid gland homogeneously enlarged

Respiratory: shortness of breath, cough without sputum

Musculoskeletal: joint pain without stiffness

Endocrine: heat intolerance

 General: Mrs. A.S. was quietly resting on the side of her
bed without any apparent sign of distress. She seems well
oriented in time, person and place.

Physical Skin: no warmth, bruises, rashes or cyanosis

Examination
Eyes: no hemorrhage or exudates.

Neck: trachea in the midline; increased thyroid size (easily

palpated)

Musculoskeletal: no tenderness, no subcutaneous nodules.

Muscular strength 4+/5+ all four limbs.
Vital signs & Laboratory values

Vital signs June 18 June 26 Thyroid

Hormones  
Temperature 98.9˚F 99.8˚F   Normal Lab

Blood pressure 124/80 121/78

T4 0.93-1.71 7.77

Pulse 129 90 T3 0.8-2.0 6.07

Respiratory 19 20 TSH 0.27-4.20 <0.005

rate
 Summary
Assessment & Plan
 A.S., a 41-year-old woman with a past medical
history of anemia, presented with weakness,
fatigue, hand tremors, itchy skin and palpitations.
Summary Patient has been losing weight, with no change in
appetite or food intake. She has also been
suffering form heat intolerance and excessive
sweating. Patient was tachycardic and her blood
thyroid hormones levels where found to be high.
 Assesment & Plan

Hyperthyroidism Chronic Anemia

High levels of thyroid hormones (free thyroxine and free tri- Weakness and fatigue can be associated with
iodothyronine) and decrease levels of TSH indicate primary exacerbation of preexisting anemia
hyperthyroidism, most common cause is Grave’s disease
Plan
Plan
• Thyroid ultrasound, Radioiodine Uptake Test and screen for
• CBC, Iron studies (iron, ferritin and TIBC
TRAb
levels), blood smear
• Monitor thyroid hormone levels and treat associated
• Continue Trihemic regimen
symptoms
• Continue regimen of Carbimazole, Propanolol, Loratidine
and Piriton
Introduction

Epidemiology
 Introduction

Hyperthyroidism/ thyrotoxicosis is a clinical syndrome of hypermetabolism associated with raised serum total, free T3 and/ or T4
concentration.
Most common cause is Grave’s disease, which is an organ specific autoimmune disease and is the only autoimmune disease being
associated with target organ hyperfunction rather than organ damage.
Another common cause of hyperthyroidism is multinodular goiter.

Rare causes include thyroid adenoma and thiroiditis 

Secondary causes 

TSH secreting pituitary tumor

Ovarian teratoma with ectopic thyroid tissue 

Exogenous administration of thyroid hormone

Introduction
  Graves disease has an incidence of
approximately 4 per 10,000 people per year
world wide
 Prevalence of hyperthyroidism in the United
States  is 1-2% with an incidence of
20/100,000 
 Graves disease is more prevalent in women and
can be as much as 10 times more frequent in
females than males
 Lifetime risk in women and men is 3% and
0.5% respectively 
 About 30 % of graves disease have family
members who have graves disease 
 Increased incidence amongst African
Americans.
 Pathogenesis &
Pathophysiology
 Type II Hypersensitivity autoimmune
disorder due to genetic and
Pathogenesis environmental interactions that lead to
loss of immune tolerance to thyroid
antigens. 

Associated with HLA-DR3 and HLA-B8.

Also they have found that the genes
directly associated to any thyroid disease
are CD40, CTLA-4, thyroglobulin, TSH
receptor, and PTPN22.
 Autoantibodies (IgG) directed against:
 Thyroid Stimulating Hormone
receptor 
Pathogenesis  Thyroglobulin 
 Thyroid peroxidase
 Sodium iodide symporter 
Pathophysiology

TSH receptor antibodies 

 Mimic TSH and stimulate T3 and T4  
formation leading to hyperthyroidism. 
 This increase in thyroid hormones will
cause negative feedback leading to
decrease levels of TRH and TSH.
 Stimulate iodine uptake, protein
synthesis and thyroid gland growth .
Pathophysiology

The over stimulation of the thyroid gland will

lead to the hypertrophy of the follicular cells
(Goiter).
 This follicles are lined by tall columnar
epithelial cells that will resorb colloid in
the centers of the follicles leading to
“scalloped” appearance.
Pathophysiology

TSH receptor antibodies can cross and affect other receptors for example in the eye
or skin, this leading to some classical symptoms of the disease.
Ophthalmopathy 
 Increase volume of retro orbital connective tissue by activation of fibroblast 
 Marked infiltration, swelling 

Dermopathy 
 Pretibial myxedema
Clinical Features

Diagnosis
Clinical Features

Prominence of
Anxiety and Enlargement of Fine tremor on Irregular
eyes, puffiness of
irritability the thyroid gland hands and fingers heartbeats
lids

Increase sensitivity Thick, itchy, red

Tachypnea on Change in texture
Weight loss to heat and skin usually on the
exertion of skin and nails
perspiration shins

Changes in Anxiety and Pretibial

Brittle hair Hyperreflexia
menstrual cycles irritability Mixedema
 Diagnosis

History and Physical Examination: Laboratory findings:

Signs: Blood Test:

 Tachycardia  Elevated levels of free Thyroxine (fT4) and free Triiodothyronine (fT3)and
decreased TSH.
 Hyperreflexia
 Presence of TRAb
 Moist & warm skin
Thyroid Ultrasound:
Symptoms:
 Sensitive imaging to detect presence of thyroid nodules. It is also useful to evaluate
 Weight loss
vascularity of the thyroid gland and focal masses if a color Doppler flow exam is
 Goiter done.
 Heat intolerance Radioiodine uptake test:
 Tremors  RAIU is a type of nuclear test that measures how much radioactive iodine is taken
up by the thyroid gland in a given time period.
 Palpitations
Treatment
 • Age of the patient
• Severity of hyperthyroidism
It is
Treatment
• Goiter size
• Presence of ophthalmopathy
based on: • Response to medications
• Comorbidities
• Pregnancy

• They are part of the initial management, but

Beta only if the patient presents with

thyrotoxicosis.

blockers: • They will help to relief the adrenergic

symptoms like tachycardia, until the thyroid
hormone levels are back to normal.
Treatment

• Methimazole, Propylthiouracil and Carbimazole are the drugs of choice to treat the
hyperthyroidism.

Antithyroid drugs • They can be used as primary treatment, as a pre-treatment before radioactive iodine
therapy or before thyroidectomy.
• Pregnancy: use Propylthiouracil during the first trimester to reduce the risk of birth
defects.

Radioactive Iodine • This type of iodine will destroy the thyroid cells, including the cancerous cells, until
the thyroid is destroyed.
Therapy (RAI/I- • Used in patients with comorbidities that increase surgical risk, women who plans
pregnancy 6 months after therapy or to remove any kind of cancerous lesions left
131) behind during surgery.
Treatment

• Total or partial removal of the thyroid gland.

Thyroidectomy • Used in women planning a pregnancy in the next 6 months, enlarged goiter with
compression of surrounding organs, patients with thyroid nodules larger than 4 cm,
hypofunctioning thyroid or patients with grave’s ophthalmology.

• It is recommended that all patients with Graves disease should stop smoking.
Smoking cessation • Smoking can reduce the treatment effectiveness and increase the thyroid hormone
levels.

Grave’s • Additional to the normal treatment, oral corticosteroids should be given to reduce

Ophthalmopathy the swelling in the eyes.

 Course

Prognosis

Prevention
 Course
 Grave’s disease is usually acute.
 The presentation can vary
significantly amongst different
patient groups.
 Thyroid eye disease affects up to
50% of patients with Graves'
disease.
 Exophthalmos
(hyperthyroidism caused by
Grave’s)
 Chemosis
 Impaired extra-ocular muscle
movement 
Prognosis

 Palpable goiter was associated with worse prognosis compared

with no goiter.
 No significant differences are seen in prognosis for gender and
age.
 Current smoking is more common among GD patients.
 If a patient remains euthyroid for 4–5 years after completion of
the treatment, the risk of a further relapse is less.
Prevention
Citations

 Subekti, I., & Pramono, L. A. (2018). Current Diagnosis and Management of Graves’ Disease. Acta Medica
Indonesiana, 50(2), 177–182. Retrieved from http://search.ebscohost.com/login.aspx?
direct=true&db=mdc&AN=29950539&site=eds-live
 Goichot, B., Leenhardt, L., Massart, C., Raverot, V., Tramalloni, J., & Iraqi, H. (2018). Diagnostic procedure in
suspected Graves’ disease. Annales d’Endocrinologie, 79(6), 608–617. https://doi.org/10.1016/j.ando.2018.08.002

 DeGroot LJ. Diagnosis and Treatment of Graves’ Disease. [Updated 2016 Nov 2]. In: Feingold KR, Anawalt B, Boyce A,
et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK285548/

 Chaudhary, V., & Bano, S. (2013). Thyroid ultrasound. Indian journal of endocrinology and metabolism, 17(2), 219–
227. doi:10.4103/2230-8210.109667
 Citations

 Graves disease in adults. In DynaMed [database online]. EBSCO Information Services.

http://www.dynamed.com/topics/dmp~AN~T115280/Graves-disease-in-adults. Updated April 01, 2019. Accessed July 22, 2019. 
 Sawicka-Gutaj, N. (2014). Influence of cigarette smoking on thyroid gland--an update. Endokrynologia Polska, 65, 54-62.
 Subeki, I., & Pramomo, L. A. (2018, April). Current Diagnosis and Management of Grave's Disease. Acta Med Indones - Indones J Intern Med, 50(2),
177-182.
 American Cancer Society medical team.  (2019, March 14). American Cancer Society. Retrieved from
https://www.cancer.org/cancer/thyroid-cancer/treating/radioactive-iodine.html 
 Unknown. (2018, December). Retrieved from Harvard Health Publishing:
https://www.health.harvard.edu/a_to_z/graves-eye-disease-graves-ophthalmopathy-a-to-z 
 Sai-Ching Jim Yeung, M. P. (2018, March 23). Graves Disease. Retrieved from Medscape:
https://emedicine.medscape.com/article/120619-overview#showall 
 Stephanie L Lee, M. P. (2018, March 15). Hyperthyroidism and Thyrotoxicosis . Retrieved from Medscape :
https://emedicine.medscape.com/article/121865-overview#a4  
 Citations

 Mark P. J. Vanderpump, The epidemiology of thyroid disease, British Medical Bulletin, Volume 99, Issue 1, September
2011, Pages 39–51, https://doi.org/10.1093/bmb/ldr030
 The thyrotropin receptor autoantigen in Graves disease is the culprit as well as the victim. Chun-Rong Chen, … , Basil
Rapoport, Sandra M. McLachlan. Published June 15, 2003. Citation Information: J Clin Invest. 2003;111(12):1897-1904.
https://doi.org/10.1172/JCI17069.https://www.jci.org/articles/view/17069#SEC1 
 Pokhrel B, Bhusal K. Graves Disease. [Updated 2019 Jun 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2019 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK448195/https://www.ncbi.nlm.nih.gov/books/NBK448195/

 2018 European Thyroid Association Guideline for the Management of Graves’ Hyperthyroidism . Kahaly G.J.a Bartalena
L.b · Hegedüs L.c · Leenhardt L.d · Poppe K.e · Pearce S.H.f https://www.karger.com/Article/FullText/490384
Thank You!