Graves' Disease - Hyperexcision

Last updated: March 19, 2026

Graves’ disease is an autoimmune thyroid condition caused by thyrotropin-stimulating immunoglobulins (TSIs), which bind to TSH receptors, resulting in elevated basal thyroid activity.

It is the most common cause of hyperthyroidism. It is more common in women than in men. It peaks between 20 and 40 years, and is associated with other autoimmune disorders (HLA-B8)

Unlike toxic adenoma, 50% of patients with Graves’ disease undergo remission within the first year of treatment. This is why medical treatment, instead of surgery, is preferred for Graves’ disease.

Risk factors
- Family history
- Female sex
- Smoking – increases the risk of orbitopathy
Triggers
- Stress
- Infection
- Childbirth
Associated conditions
- Vitiligo
- Type 1 diabetes
- Addison’s disease
- Pernicious anaemia
Pathophysiology
- Production of TSIs → TSIs bind to TSH receptors, causing chronic stimulation → excessive production of T3 and T4 and thyroid gland hypertrophy
- TSIs bind to TSH receptors in the retro-orbital and dermal tissues → proliferation of orbital and dermal fibroblasts, synthesis of hyaluronic acid, and differentiation into adipocytes → exophthalmos and pretibial myxoedema
- Initially hyperthyroid but may become euthyroid or hypothyroid.
Signs and symptoms
- Symptoms of hyperthyroidism
- Eye disease (30%)
  - Exophthalmos
  - Upper eyelid retraction
  - Ophthalmoplegia
  - Eye pain
  - Tearing
  - Diplopia
  - Photophobia
  - Blurred vision
- Pretibial myxedema (3%)
- Thyroid acropachy (1%)
- Tachycardia
- Goiter
- Warm/moist skin
- Fine tremor
Differentials
- Toxic nodular goitre
- Subacute thyroiditis (de Quervain)
- Gestational hyperthyroidism
- TSH-producing pituitary adenoma
- Iodine-induced hyperthyroidism
- Myasthenia gravis
- Postnatal thyroiditis
- Thyrotoxicosis factitia
Investigations
- Thyroid function test:
  - Low TSH
  - High T3 and T4
  - A high T3/T4 ratio suggests Graves’ disease over thyroiditis
- Serology for Thyroid-stimulating immunoglobulin (TSI): most accurate test
  - TSH receptor-stimulating antibodies (90%)
  - Anti-thyroid peroxidase antibodies (75%)
- Complete blood count
  - Normocytic anaemia
- Calcium
  - Hypercalcemia (T3 activates osteoclasts
- RAIU scan
  - Diffuse increased uptake
Medical treatment
- Propranolol to control symptoms of hyperthyroidism
- Antithyroid drugs
  - Carbimazole (first-line)
  - Propylthiouracil (choice in pregnant women in the first trimester)
- Radioiodine ablation (radioactive iodine) is the definitive treatment
- Steroids and/or Teprotumumab (Tepezza) for Graves’ ophthalmology and myxedema (may not respond to antithyroid medication)
Surgical treatment
- Bilateral subtotal thyroidectomy
Contraindications for radioactive iodine ablation
- Pregnant or nursing mothers
- Patients with moderate-to-severe ophthalmopathy
- Patients who smoke (worsens ophthalmopathy)
- Patients with large goiters
- Patients with severe thyrotoxicosis requiring rapid control
Complications of hyperthyroidism
- Atrial fibrillation
- Pregnancy-related complications
  - Miscarriage
  - Pre-term birth
  - Thyroid dysfunction in the foetus
  - Pre-eclampsia
  - Maternal heart failure
- Osteoporosis
- Congestive heart failure due to thyrotoxic cardiomyopathy (high-output failure)
- Thyroid storm
Complications of thyroidectomy
- Thyroid storm
- Hemorrhage
- Hypoparathyroidism
- Recurrent Laryngeal Nerve Injury

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

Calculator ›

Graves’ Disease

Post DiscussionCancel Reply