**4. Clinical features**

Clinical manifestations of Graves' Disease related to age of onset, severity and the duration of hyperthyroidism. Symptoms and signs (**Table 1**) are result from hyperthyroidism or a consequence of underlying autoimmunity. Weight loss, fatigue, heat intolerance, tremor, and palpitations are the most common symptoms, occurring in more than 50% of patients. Elderly person more commonly presents with Weight loss, decreased appetite, and cardiac manifestations. Atrial fibrillation is seen in more than 10% of elderly but rare in younger patients. Goiter presents in most of younger patients with thyrotoxicosis but less common in older patients. Goiter is


#### **Table 1.**

*Major symptoms and physical signs in Graves' Disease.*

#### *Graves' Disease: A Review DOI: http://dx.doi.org/10.5772/intechopen.98686*

present most commonly as diffuse thyroid enlargement but nodular goiter can also be present perticularly in those who reside in iodine deficient areas (**Figure 1**).

Varying degree of orbital involvement can be seen in GD which is a consequence of thyroid autoimmunity which occur parallel to the thyroid involvement. It usually present with tearing, congestion, redness and irritation in eyes. In severe cases proptosis may occur due to inflammation and edema of extraoccular muscle and retrobulbar tissue expension owing to fluid accumulation as a result of accumulation of glycolsaminoglycan. Double vision and sight threatening complications i.e. corneal ulceration, dysthyroid optic neuropathy can occur as a consequence of damage to extraoccular muscles. For selecting appropriate patient for treatment EUGOGO classified GO in mild, moderate to severe and sight threatening. Activity of GO can be easily assessed by clinical activity score (CAS) (**Table 2**). A CAS ≥3/7 is indicative of active GO (**Figure 2**).

#### **Figure 1.** *Graves' orbitopathy.*


**Table 2.** *Measures of clinical activity score (CAS).*

#### *Graves' Disease*

**Figure 2.** *Graves' dermopathy.*

**Figure 3.** *Thyroid acropachy.*

Graves' dermopathy is seen in 1–4% case of GD. It frequently localize to pretibial region but it may be seen on elbow, feet, toe and areas of trauma. Lesion can be described as erythematous, non-pitting thickening of dermis in pretibial region. In mild cases it gives "orange Peel" appearance. Graves' dermopathy is almost always associated with GO (**Figure 3**).

Acropachy is very rare extrathyroidal manifestation of GD. Acropachy is defined as skin tightness, digital clubbing, small-joint pain, and soft tissue edema progressing over months or years with gradual curving and enlargement of the fingers [43]. The pathogenesis of acropachy is not known. In most of cases acropachy remain asymptomatic.

#### **5. Diagnosis**

#### **5.1 Graves' hyperthyroidism**

Diagnosis of GD is based on clinical manifestations of thyrotoxicosis and biochemical abnormalities. If orbitopathy is present than diagnosis of GD is certain but in the absence of orbitopathy serum TSH Receptor Antibody (TRAb) and imaging may be required to for the diagnosis.
