Graves disease

Last revised by Dr Mohammad Taghi Niknejad on 20 Sep 2022

Graves disease, also known as Basedow disease in mainland Europe 9, is an autoimmune thyroid disease and is the most common cause of hyperthyroidism.

There is a strong female predilection (F:M of 5:1), and is most common between 30 and 60 years 14. The incidence is 20 cases per 100,000 people 14.

Pediatric Graves disease accounts for 5% of all cases (incidence 5 per 100,000 children). It is more common in older adolescents. There is a lower female prediction in children (F;M of 3.5:1) 15.

Patients are thyrotoxic with common symptoms being tremor, heat sensitivity, unexplained weight loss, anxiety, goiter, etc. 14. Extrathyroidal manifestations include:

The combination of exophthalmos, palpitations, and goiter is called the Merseburger (or Merseburg) triad.

Graves disease results from an antibody-directed stimulation of the thyroid-stimulating hormone (TSH) receptor, with the production and release of T3 and T4 resulting in hyperthyroidism 14.

The pathogenesis of Graves disease is not fully known 15. Genetic predisposition accounts for 80% of the risk of Graves disease, with environmental factors (e.g. smoking, iodine excess, selenium deficiency, vitamin D deficiency) accounting for the rest 14.

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

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
  • TSH receptor antibodies (TSI, TGI, TBII): positive

10x increased relative risk of the following autoimmune diseases 16:

  • 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 color Doppler 1
  • iodine-123: imaging performed at around 2-6 days; classically demonstrates homogeneously increased activity in an enlarged gland
  • technetium-99m pertechnetate: homogeneously increased activity in an enlarged thyroid gland

Antithyroid medications (e.g. methimazole/carbimazole) are the first-line treatment. In medication-resistant Graves disease, patients can go onto radioactive iodine or thyroidectomy 14,15.

It is named after Robert James Graves (1796-1852), an Irish surgeon who first described it in 1835 9, and Carl Adolph von Basedow (1799-1854), a German physician who described it in 1840 10,11,13. The Merseburger triad was first described by Basedow, who practised in Merseburg 12,13.

For hyperthyroidism consider: 

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Cases and figures

  • Figure 1: macroscopic pathology
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  • Case 1: with "thyroid inferno" appearance
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  • Figure 2: histology
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  • Case 3: thyroid scintigraphy
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  • Figure 3: histology
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  • Case 2: with thyroid orbitopathy
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  • Case 4: on ultrasound
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  • Case 5: on Doppler
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  • Case 6: on CT
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  • Case 7: graves disease
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  • Case 8: graves disease
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