What is Graves Disease (Toxic Diffuse Goiter)?

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Graves disease (Toxic Diffuse Goiter)

Graves disease, also known as Basedow’s disease or diffuse toxic goiter, is an autoimmune condition in which a person’s immune system mistakenly stimulates the thyroid gland to produce excess amounts of thyroid hormone, causing hyperthyroidism and sometimes eye problems. It is the most common cause of hyperthyroidism.^[1]

The thyroid is a small, butterfly-shaped gland in the lower part of the neck, positioned below the voice box. Hormones released by the gland control the body’s metabolism, playing a key role in processes like digestion, temperature, heart rate, and growth. If the levels of these hormones go too low or too high and are not corrected, a person can experience a range of unpleasant and potentially dangerous effects and complications.^[1][2]

Symptoms of Graves’ disease may include:^[1]

• Nervousness
• Racing heart or palpitations, i.e. pronounced awareness of one’s heartbeat
• Difficulty sleeping
• Intolerance to heat
• Feeling tired and/or weak
• Swelling of the thyroid, i.e. development of a goiter
• Irritation and bulging of the eyes, known as Graves’ ophthalmopathy or thyroid eye disease

Treatment for Graves’ disease depends on the particular person. Still, it may include medication to reduce the amount of thyroid hormone being produced, radioiodine therapy, and, in some cases, surgery to remove the thyroid gland. The condition may go into remission and then relapse. Treatment and monitoring are usually lifelong.^[1][3][4]

With careful management by a doctor who specializes in hormonal conditions, an endocrinologist, the outlook is excellent, and many people with Graves’ disease can enjoy a full, healthy life.^[5][6]

However, untreated or poorly treated Graves’ disease can lead to serious complications, including an increased risk of bone fractures, cardiovascular disease, and stroke, as well as thyroid storm. In the case of Graves’ eye disease, vision loss may occur.^[3][7][8]

Diffuse toxic goiter can affect people of any age, though it tends to be more prevalent in adults, particularly those between the ages of 20 and 50, than children. It is more common in women than men and often runs in families, meaning that several family members may have the same condition.^{[1][3][9][10][11][12]}

Graves’ disease symptoms

A person with Graves’ or Basedow’s disease may develop general signs and symptoms of hyperthyroidism, including:^{[1][5][13][14]}

• Anxiety or nervousness
• Irritability, agitation or restlessness
• Rapid or irregular heartbeat or palpitations
• Sleep disturbances, i.e. insomnia
• Increased sweating, body warmth and heat intolerance
• Fatigue and weakness
• Difficulty exercising
• Tremors, i.e. shaky hands
• Having more bowel movements than usual
• Unexplained weight loss or difficulty gaining weight; in some cases there may be weight gain due to increased appetite
• Hair loss
• Erectile dysfunction in men

Symptoms may develop gradually and may seem to come and go. In some people, there may be swelling of the thyroid gland, called a goiter. This may be noticeable as a bulge in the front of the neck.^[1][2][10] Read more about symptoms of hyperthyroidism.

Graves’ disease symptoms in females

In women, Graves’ disease may also cause menstrual irregularities, including:^[1][13]

• Very light periods
• Infrequent periods
• Absence of periods

Bulging eyes and other eye symptoms: Graves’ ophthalmopathy (thyroid eye disease)

An estimated 25 to 50 percent of people with Graves’ disease experience eye symptoms, sometimes without the other symptoms of hyperthyroidism. These eye symptoms are caused by a condition called Graves’ ophthalmopathy, Graves’ orbitopathy, or thyroid eye disease; despite the name, they can also occur in people without thyroid problems. Eye symptoms may include:^[8][13][15]

• Irritation, tearing or dryness in the eyes; the eyes may feel gritty
• Redness of the eyes and eyelids
• Swelling of the upper eyelids
• Sensitivity to light
• Bulging of the eyes
• Pain in or behind the eyes, particularly when looking up or to the side

In most cases, the eye symptoms of Graves’ disease are mild and easy to treat. However, in a small number of patients, they can be very serious and damage a person’s vision. Some of the more severe symptoms of thyroid eye disease include:^[8][13][15]

• Inability to move the eyes
• Ulcers on the cornea (the outer layer of the eye)
• Blurred or double vision
• Loss of vision and blindness (rare)

If you are experiencing any eye problems and suspect that you may have a thyroid eye disease, it is recommended that you see a doctor without delay.

Graves’ dermopathy (pretibial myxedema)

A small number of people with Graves’ disease develop red, thick, swollen areas of skin, typically on the shins and the top of the feet. This is called pretibial myxedema, thyroid dermopathy, or Graves’ dermopathy and is most often seen in people who also have eye symptoms.^[1][16]

Causes of Graves’ disease

Graves’ disease is an autoimmune condition, which means that it is caused by the body’s immune system mistakenly targeting healthy tissue, in this case, the thyroid gland. Graves’ disease occurs when immune system proteins (antibodies), which generally attack bacteria and viruses, start attacking the thyroid gland. This causes the thyroid gland to secrete more thyroid hormone than is needed by the body, leading to hyperthyroidism.^[17]

Risk factors

It is not understood exactly what causes the immune system to target the thyroid gland, but hereditary factors are thought to be involved. Specific genes passed down in families seem to make a person more likely to develop Graves’ disease. If a relative has the condition, the risk is increased.

It is thought that other risk factors for the development of the disease may include:^{[9][18][19][11][20][21]}

• Being female
• Having been pregnant recently
• Having another autoimmune condition, e.g. type 1 diabetes, Hashimoto’s thyroiditis or rheumatoid arthritis
• Severe stress
• High iodine intake
• Smoking tobacco; this is also associated with worsening of Graves’ eye symptoms
• Certain medications, e.g. Interferon beta-1b
• Certain infections, e.g. Yersinia enterocolitica
• Injury to the thyroid gland, e.g. through surgery

Causes of Graves’ ophthalmology

Graves’ ophthalmology is not the result of excess thyroid hormone in the body but rather inflammation and swelling in the tissues behind the eyes. This swelling pushes the eyeballs forward, causing bulging and other symptoms. The same antibodies that mistakenly stimulate the thyroid gland to produce high thyroid hormone levels mistakenly target these tissues in some people. However, the exact reason for this is not clearly understood.^[15][18][22]

Smoking tobacco is a risk factor in the development and worsening of thyroid-associated eye disease.^[15][22]

Diagnosis of Graves’ disease

The first step in diagnosing Graves’ disease is typically a visit to a doctor, who will take the person’s medical history and perform a physical examination. If Graves’ disease is suspected, doctors will usually order blood tests to check thyroid hormone levels and levels of thyroid antibodies. An ultrasound scan of the thyroid gland and/or radioactive iodine uptake test may also be needed. These imaging tests can help the doctor to see whether any swelling or nodules, which are small lumps, are present.^[1]

Graves’ disease tests

Blood tests

These can measure levels of the following:^{[1][3][5][11][23][24]}

Thyroid-stimulating hormone (TSH): This varies according to how much thyroid hormone is needed by the body at any given time. TSH levels are usually very low in Graves’ disease and many other conditions that cause hyperthyroidism.

Free thyroxine (FT4): This is a form of thyroid hormone that is converted into the biologically active T3. FT4 levels are usually high when Graves’ disease is present.

Free triiodothyronine (FT3): Not always measured. However, FT3 levels are usually high when Graves’ disease is present.

Good to know: If TSH is low, but FT4 and FT3 levels are normal, the person may have what is known as mild or subclinical hyperthyroidism. They will typically need to have follow-up tests in a couple of months to see whether there has been any change. Depending on the results and the particular person, the doctor may recommend treatment based on the initial findings.^[1][25]

Thyroid antibodies: Graves’ disease is typically characterized by high levels of thyroid antibodies, particularly thyroid-stimulating immunoglobulin (TSI), as well as thyroid-stimulating hormone receptor antibodies (TSHR Ab), also known as TSH receptor antibodies (TRAbs). High levels of thyroid peroxidase antibodies (TPO) and anti-thyroglobulin antibodies (Tg) are often detected in people affected by Graves’ too.

Thyroid ultrasound

A non-invasive scan of the throat region, a thyroid ultrasound can help to identify nodules and swelling, thereby helping to identify the cause of the hyperthyroidism.^[23]

Radioactive iodine uptake test and thyroid scan

To confirm the diagnosis, a doctor may recommend a test in which the person is given a very small dose of a weakly radioactive substance and then undergoes a special imaging scan. Because the thyroid takes up iodine, this test can provide insights into how the thyroid is functioning and what the cause of the hyperthyroidism may be. It is generally safe for most people but is not recommended for pregnant women.^[1][23][26]

Differential diagnosis

It is important to distinguish signs and symptoms of Graves’ disease from other conditions that can sometimes present in similar ways, such as other thyroid problems, anxiety disorder, or bipolar disorder. Blood tests and the other tests detailed above help ensure an accurate diagnosis.^[27]

Graves’ disease treatment

Treatment for Graves’ disease is generally the same as treatment for hyperthyroidism. It typically requires lifelong monitoring and management of thyroid hormone levels, with the help of an endocrinologist and general practitioners, to ensure that they remain in the acceptable range. Depending on the particular person and their circumstances, treatment options may include:^[1][5]

• Antithyroid medication; this is the term for medicine aimed at reducing thyroid function
• Radioiodine therapy
• Thyroid surgery

Read more about hyperthyroidism treatment.»

Thyroid eye disease treatment

In many cases, Graves’ orbitopathy clears up on its own, without any specific treatment. However, in other cases, treatment may be necessary. This may include:^[8]

• In mild cases, cool compresses, lubricating eye drops and sunglasses
• Corticosteroid medication
• In severe cases, surgery

A person with thyroid eye disease will be referred to a doctor specializing in the eyes, called an ophthalmologist, to manage the condition.

Good to know: Smoking tobacco increases the risk of developing a thyroid eye disease and the risk of complications from thyroid eye disease and should be avoided.^[8][22]

Pretibial myxedema treatment

The skin lesions that some people with Graves’ disease develop do not generally cause discomfort and are not usually serious. However, they can be unsightly. Treatment for thyroid dermopathy is often not necessary, but where recommended typically involves the application of corticosteroid creams. People with more severe pretibial myxedema may find that wearing compression stockings is also helpful in providing relief.^[28][29]

Good to know: Almost all people who develop pretibial myxedema also have fairly severe thyroid eye disease.^[29]

Complications of Graves’ disease

If it is left untreated or medical advice is not adequately followed, Graves’ disease can cause serious complications. These include:^[3]

• Eye damage and vision loss, in the case of thyroid eye disease^[8][22]
• Hypothyroidism if thyroid hormone levels are not adequately monitored and managed^[11]
• Thyroid storm
• Other complications

Read more about thyroid storm and other complications of hyperthyroidism.»

Graves’ disease FAQs

Other names for Graves’ disease

• Basedow’s disease
• Toxic diffuse goiter/Diffuse toxic goiter

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1. Adoctor. “Hyperthyroidism.” Accessed September 13, 2018. ↩ ↩ ↩ ↩ ↩ ↩ ↩ ↩ ↩ ↩ ↩ ↩ ↩ ↩ ↩ ↩

2. The Guardian. “Balancing act.” March 18, 2001. Accessed September 14, 2018. ↩ ↩

3. Patient. “Hyperthyroidism.” December 10, 2015. Accessed September 14, 2018. ↩ ↩ ↩ ↩ ↩

4. Medscape. “Graves Disease Treatment & Management.” March 23, 2018. Accessed September 18, 2018. ↩

5. MedlinePlus. “Graves disease.” February 22, 2018. Accessed September 14, 2018. ↩ ↩ ↩ ↩

6. European Journal of Endocrinology. “Long-term prognosis after medical treatment of Graves’ disease in a northern Swedish population 2000-2010.” February 4, 2014. Accessed September 14, 2018. ↩

7. Mayo Clinic News Network. “Graves’ Disease Rarely Life-threatening But Can Lead to Heart Problems, Weak Bones.” August 26, 2011. Accessed September 14, 2018. ↩

8. Harvard Health Publishing. “Graves’ Eye Disease (Graves’ Ophthalmopathy).” January, 2013. Accessed September 14, 2018. ↩ ↩ ↩ ↩ ↩ ↩

9. Medscape. “Graves Disease: Epidemiology.” March 23, 2018. Accessed September 14, 2018. ↩ ↩

10. Hackensack Meridian Health, Jersey Shore University Medical Center. “Hyperthyroidism & Graves’ Disease.” Accessed September 15, 2018. ↩ ↩

11. Amboss. “Graves disease.” August 31, 2018. Accessed September 17, 2018. ↩ ↩ ↩ ↩

12. Endocrine. “Epidemiology, management and outcomes of Graves’ disease—real life data.” May 6, 2017. Accessed September 17, 2018. ↩

13. Genetics Home Reference. “Graves disease.” September 11, 2018. Accessed September 15, 2018. ↩ ↩ ↩ ↩

14. Medscape. “Graves Disease Clinical Presentation.” March 23, 2018. Accessed September 18, 2018. ↩

15. British Thyroid Foundation. “Thyroid Eye Disease.” 2015. Accessed September 15, 2018. ↩ ↩ ↩ ↩

16. Mayo Clinic. “Graves’ dermopathy: How is it treated?” July 8, 2017. Accessed September 15, 2018. ↩

17. Medscape. “Graves Disease: Background.” March 23, 2018. Accessed September 18, 2018. ↩

18. Mayo Clinic. “Graves’ disease: Symptoms & causes.” March 6, 2018. Accessed September 17, 2018. ↩ ↩

19. Healthline. “Graves’ Disease.” January 4, 2016. Accessed September 17, 2018. ↩

20. Medscape. “Hyperthyroidism, Thyroid Storm, and Graves Disease.” April 3, 2018. Accessed September 17, 2018. ↩

21. Bruce M. Wenig. 2015. “Atlas of Head and Neck Pathology E-Book”. Elsevier Health Sciences. ↩

22. Patient. “Thyroid Eye Disease.” April 11, 2018. Accessed September 17, 2018. ↩ ↩ ↩ ↩

23. Adoctor.“Thyroiditis.” Accessed September 18, 2018. ↩ ↩ ↩

24. Medscape. “Graves Disease Workup.” March 23, 2018. Accessed September 18, 2018. ↩

25. American Family Physician. “Subclinical Hyperthyroidism: What It Means to You.” April 15, 2011. Accessed September 19, 2018. ↩

26. Mayo Clinic. “Graves’ disease: Diagnosis & treatment.” March 6, 2018. Accessed September 19, 2018. ↩

27. Medscape. “Graves Disease Differential Diagnoses.” March 23, 2018. Accessed September 18, 2018. ↩

28. Medscape. “Pretibial Myxedema Treatment & Management.” February 2, 2016. Accessed September 24, 2018. ↩

29. American Journal of Clinical Dermatology. “Pretibial myxedema: pathophysiology and treatment options.” 2005. Accessed September 24, 2018. ↩ ↩

30. UpToDate. “Pathogenesis of Graves’ disease.” November 14, 2017. Accessed September 14, 2018. ↩

31. British Thyroid Foundation. “Thyroid and Diet Factsheet.” Accessed September 13, 2018. ↩

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**What is Graves Disease (Toxic Diffuse Goiter)?**



**Q: What is Graves Disease?**

**A:** Graves ​Disease, also known as Toxic Diffuse Goiter, is an‍ autoimmune disorder‍ that ⁢affects the thyroid gland. The thyroid gland produces⁢ hormones that regulate metabolism, growth, ​and development. In Graves Disease, the immune system mistakenly attacks the⁤ thyroid gland, causing it to overproduce thyroid hormones.



**Q: ​What causes‍ Graves Disease?**

**A:** The exact cause ⁤of Graves Disease is unknown, but it is thought to⁢ be linked to inherited genes and environmental triggers⁢ such as stress, infection, or certain medications.



**Q: What‍ are the ​symptoms of Graves Disease?**

**A:** Symptoms of Graves Disease can include:

* Increased metabolism (weight loss, heat intolerance)

* Fast or irregular heartbeat (tachycardia)

*​ Enlarged thyroid gland ‌(goiter)

* Bulging ⁢eyes (exophthalmos)

* Muscle weakness

* Diarrhea

* Tremors

* Irritability

* Difficulty sleeping



**Q: How is Graves Disease diagnosed?**

**A:** Graves ⁢Disease is diagnosed ⁤through a combination of tests including:

* Physical examination

* Blood tests to measure thyroid hormone levels

* Thyroid uptake and scan to assess thyroid function



**Q: How is Graves ‍Disease treated?**

**A:** Treatment options ⁢for Graves Disease ⁢include:

* Medications to block thyroid hormone production ⁣(antithyroid⁢ drugs)

* Radioactive iodine therapy to shrink the ‍thyroid gland

*⁢ Surgery to remove part or all of the thyroid gland



**Q: What ⁣are the complications of Graves Disease?**

**A:**‌ If left untreated, Graves Disease can‌ lead to complications such as:

* Heart failure

* Bone loss

* Eye damage

* Infertility



**Q: ‌Is there a cure for ⁢Graves Disease?**

**A:** There is no cure for Graves Disease, but it can be managed with treatment to control thyroid hormone levels. With‍ proper treatment, ⁣most people with Graves Disease can ‌live normal ⁢and ⁣healthy lives.



**Additional Keywords:**



* Graves Disease

* Toxic Diffuse Goiter

* Autoimmune disorder

* Thyroid gland

* Thyroid hormones

* Metabolism

* Tachycardia

* ⁤Goiter

* Exophthalmos

* Diagnosis

* Treatment

* Complications