The change in the clinical presentation of Graves’ disease: a 30 years retrospective survey in an academic Brazilian tertiary center

Abstract

Objective: Graves' disease (GD) is the main cause of hyperthyroidism among adults. It is an autoimmune condition classically marked by the Merserburg Triad (goiter, thyrotoxicosis, and orbitopathy), but the change in presentation of GD over time has rarely been studied. To determine changes in the clinical presentation of patients with GD in the last 30 years. Subjects and methods: The study evaluated 475 patients diagnosed with GD between 1986 and 2016 in a single center. Patients were evaluated regarding epidemiological aspects, thyroid function, inflammatory activity of the eyes evaluated by the Clinical Activity Score; CAS, severity evaluated by NOSPECS classification and thyroid volume estimated by ultrasonography. Results: Patients assessment identified an increase in the mean age of diagnosis of GD (p < 0.02), a reduction in thyroid volume (p < 0.001) and less intense orbital involvement from 2007-2016 compared to 1986-2006 (p = 0.04). The number of smoking patients was smaller from 2007 to 2016 (28.7%) than 1986 to 2006 (42.8% p = 0.001). The TSH and TRAb values did not had significant changes. Conclusion: GD presentation appears to be changed in the last years compared to the typical initial presentation. There is a less frequent inflammatory involvement of orbital tissue, smaller goiters, a lower number of smokers and diagnosis at older age.

In Graves’ disease, thyroid autoantibodies and ultrasound features correlate with distinctive histological features

“…Indeed, to our great surprise, we did not observe the previously reported correlation between TRAbs levels and thyroid volume [ 27 , 28 ]. This discrepancy is likely due to a variation in the phenotypic appearance of Graves’ disease, nowadays diagnosed earlier and in milder forms than in the past [ 23 , 29 ]. It is indeed reasonable that the extensive follicular hyperplasia reported by the oldest studies and its correlation with TRAbs levels were due to a delay in diagnosis, which enabled a prolonged stimulation of TRAbs until thyroidectomy [ 28 , 29 ].…”

“…This discrepancy is likely due to a variation in the phenotypic appearance of Graves’ disease, nowadays diagnosed earlier and in milder forms than in the past [ 23 , 29 ]. It is indeed reasonable that the extensive follicular hyperplasia reported by the oldest studies and its correlation with TRAbs levels were due to a delay in diagnosis, which enabled a prolonged stimulation of TRAbs until thyroidectomy [ 28 , 29 ]. At variance, in our patients who were thyroidectomized early after diagnosis, lymphocytic infiltration was the main determinant of thyroid volume.…”

The paths of Graves’ disease in the 21st century: precision medicine is closer

“…In this sense, the research published by Pinto and cols. (14) in this edition of Archives of Endocrinology and Metabolism (AE&M) shows, possibly owing to a decrease in smoking in Brazil, that GD had the lowest average goiter volume in the last 30 years. This outcome, i.e., the intriguing absence of goiter at the diagnosis of GD, had already been reported by some physicians in their daily practice.…”