Graves' Disease: Autoimmune Hyperthyroidism with Distinctive Eye and Skin Manifestations

Graves' disease is the most common cause of hyperthyroidism, driven by thyroid-stimulating immunoglobulins (TSI/TRAb) that activate the TSH receptor.

Classic Triad

1. Hyperthyroidism: Symptoms and biochemical confirmation.
2. Ophthalmopathy (Graves' orbitopathy): Lymphocytic infiltration of orbital fibroblasts → edema, fibrosis, muscle enlargement. Causes lid retraction, exophthalmos, diplopia, compressive optic neuropathy.
3. Dermopathy (Pretibial myxedema): Localized glycosaminoglycan deposition on shins — waxy, indurated plaques. Rare (<5%), almost always with severe ophthalmopathy.

Diagnosis

• Suppressed TSH, elevated free T4/T3.
• Positive TRAb (TSI) — confirmatory.
• Diffuse increased uptake on radioiodine scan.

Treatment

• Antithyroid drugs (methimazole) — 12–18 months; remission ~40–50%.
• Radioiodine ablation — definitive; may worsen eye disease (give steroids if moderate/severe).
• Thyroidectomy — rapid control; large goiter; patient preference.
• Eye disease: selenium (mild), steroids, teprotumumab (IGF-1R inhibitor), orbital decompression/rehab surgery.

Multidisciplinary care (endocrine, ophthalmology) optimizes outcomes.