Graves disease

Graves disease (also known as Basedow disease in mainland Europe) is an autoimmune thyroid disease and is the most common cause of thyrotoxicosis (up to 85%).


There is a strong female predilection with an F:M ratio of at least 5:1. It typically presents in middle age.

Clinical presentation

Patients are thyrotoxic. Extrathyroidal manifestations include:

The combination of exophthalmos, palpitations, and goiter is called the Merseburger (or Merseburg) triad.


Results from an antibody directed stimulation of the thyroid-stimulating hormone (TSH) receptor, with resultant production and release of T3 and T4.

Macroscopic appearance

The affected gland shows diffuse, symmetrical enlargement, with a fleshy red cut surface. This appearance can be altered by preoperative treatment or chronicity.

Microscopic appearance

The histological features are consistent with the activated state of the gland:

  • plump follicular cells with increased amounts of eosinophilic cytoplasm
  • hyperplastic follicles with papillary epithelial infoldings
  • evidence of colloid reabsorption including 'scalloping' at the apical membrane and variable follicle collapse and exhaustion

These features can be altered by preoperative treatment or chronicity.

  • TSH: suppressed
  • T4: elevated
  • T3: elevated
  • TSH receptor antibodies (TSI, TGI, TBII): positive

Radiographic features

  • thyroid gland is often enlarged and hypoechogenic, can be hyperechoic
  • heterogeneous thyroid echotexture
  • relative absence of nodularity in uncomplicated cases
  • hypervascular; may demonstrate a thyroid inferno pattern on color Doppler
Nuclear medicine
  • iodine-123: imaging performed at around 2-6 days; classically demonstrates homogeneously increased activity in an enlarged gland
  • technetium-99m pertechnetate: homogeneously increased activity in an enlarged thyroid gland

History and etymology

It is named after Robert James Graves (1796-1852), Irish surgeon, who first described it in 1835 , and Carl Adolph von Basedow (1799-1854), German physician, who described it in 1840 . The Merseburger triad was first described by Basedow who practiced in Merseburg .

Differential diagnosis

For hyperthyroidism consider:

Practical points

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