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Graves disease

Graves disease is an autoimmune thyroid disease and is the most common cause of thyrotoxicosis (up to 85%).


There a strong female predilection with the F:M ratio of at least 5:1. Typically presents in middle age.

Clinical presentation

Patients are thyrotoxic. Extra-thyroid manifestations include:


Results from an antibody directed stimulation of the thyroid-stimulating hormone (TSH) receptor, with resultant production and release of T3 and T4.

Macroscopic appearance

The affected gland shows diffuse, symmetrical enlargement, with a fleshy red cut surface. This appearance can be altered by preoperative treatment or chronicity.

Microscopic appearance

The histological features are consistent with the activated state of the gland:

  • plump follicular cells with increased amounts of eosinophilic cytoplasm
  • hyperplastic follicles with papillary epithelial infoldings
  • evidence of colloid reabsorption including 'scalloping' at the apical membrane and variable follicle collapse and exhaustion

These features can be altered by preoperative treatment or chronicity. 

  • TSH: suppressed
  • T4: elevated
  • T3: elevated
  • thyroid receptor antibodies (TSI, TGI, TBII): positive

Radiographic features

  • thyroid gland is often enlarged and can be hyperechoic
  • heterogeneous thyroid echotexture
  • relative absence of nodularity in uncomplicated cases
  • hypervascular; may demonstrate a "thyroid inferno" pattern on colour Doppler 1
Nuclear medicine
  • 123: imaging performed at around 2-6 days; classically demonstrates homogeneously increased activity in an enlarged gland
  • Tc 99 Pertechnetate: homogeneously increased activity in an enlarged thyroid gland

Differential diagnosis

For hyperthyroidism consider: 

History and etymology

It is named after Robert James Graves, Irish Surgeon (1796-1853).

Practical points

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