Graves' hyperthyroidism of recent onset and Graves' orbitopathy: To ablate or not to ablate the thyroid?

摘要

Graves' disease is an autoimmune disorder with variable phenotype and severity (Fig. 1). Graves' patients may have isolated hyperthyroidism ohifferent degrees, but in about half of them ocular involvement Graves' orbitopathy (GO) is present, ranging from mild to moderate-to-severe or (rarely) sight-threatening (1). GO is the most important and frequent extrathyroidal expression of Graves' disease, while skin involvement (thyroid der-mopathy, also called pretibial myxedema) occurs in approximately 1-4 of Graves' patients (2), and finger/nail changes (thyroid acropachy) in only 0.2-0.4 (3). In most cases dermopathy and acropachy are found in patients who have severe GO and hyperthyroidism (2, 3). It is common experience for some Graves' patients to have a severe form of the disease from its onset, with marked hyperthyroidism, moderate-to-severe (or very severe) and, active GO, with or without associated dermopathy or acropachy (Severe Graves' disease). On the other hand, there are patients whose onlyclinical feature is mild to moderately severe hyperthyroidism, without any extrathyroidai involvement (Mild Graves' disease) (Fig. 1). Do these populations have different genetic backgrounds? We do not know. Can mild Graves' disease progress to severe Graves' disease? Yes, it can. The fact that GO is absent in newly diagnosed Graves' disease does not exclude the possibility that it may develop later on with mild-to-moderate or severe features. In fact, although a close temporal relationship exists between the onset of hyperthyroidism and the onset of GO, the latter may occasionally precede hyperthyroidism or more frequently follow it (4). Occurrence or progression of GO in a Graves' patient is certainly influenced by environmental factors. Cigarette smoking, thyroid dysfunction perse, radioiodine in a definite proportion (about 15) of patients, are well-established and important risk factors, which should be corrected by appropriate actions (5).