Everything you wanted to know about Graves' disease.

Graves' disease is an autoimmune thyroid disease characterized by a genetic predisposition, an increased incidence in young women, the presence of thyroid-stimulating immunoglobulins, and an uncertain etiology. The onset occasionally follows a frightening episode in the patient's life or separation from a loved one. On physical examination, the patient has a diffuse goiter with secondary hyperthyroidism, a noninfiltrative/infiltrative ophthalmopathy, and, on occasion, an infiltrative dermopathy. Atypical symptoms, signs, and presentations such as "apathetic thyrotoxicosis" are not rare and may delay the diagnosis in some patients. The diagnosis is confirmed by elevations of bound thyroxine (T4), free T4, or bound triiodothyronine in the presence of thyroid-stimulating hormone levels of less than 0.1 mU/L. When the diagnosis is suspected, but unclear, the thyrotropin-releasing hormone stimulation test is indicated. Medical therapy must be long-term when propylthiouracil or methimazole is used, and results in only 25% to 50% remissions at 1 to 2 years. Radioactive iodine therapy has resulted in a need for retreatment in 25% to 33.7% of patients in the past, and hypothyroidism occurs in 70% to 100% of treated patients at 10 years, depending on the dose. Evolving changes in operative technique have led to a 95% to 100% cure rate with complications such as reoperation for hemorrhage (0% to 1.3%), recurrent nerve palsy (0% to 4.5%), and permanent hypocalcemia (0% to 0.6%) at extraordinarily low levels in experienced hands. Greater than 90% of patients have remained euthyroid 2 years after thyroidectomy in several series. Surgery continues to offer the highest cure rate in the shortest period of time.