Graves Disease Clinical Presentation

Updated: Jan 04, 2023
  • Author: Sai-Ching Jim Yeung, MD, PhD, FACP; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Because Graves disease is an autoimmune disorder that also affects other organ systems, taking a careful patient history is essential to establishing the diagnosis.

In some cases, the history may suggest a triggering factor such as trauma to the thyroid, including surgery of the thyroid gland, percutaneous injection of ethanol, and infarction of a thyroid adenoma. Other factors can include immunotherapy for cancer (such as the use of interferon [eg, interferon beta-1b], IL-4, and immune checkpoint inhibitors [anti–CTLA-4, anti–PD-1, and anti–PD-L1 antibodies]).

Patients usually present with symptoms typical of thyrotoxicosis. Hyperthyroidism is characterized by both increased sympathetic and decreased vagal modulation. [37] Tachycardia and palpitation are very common symptoms.

Not all patients present with such classic features. In fact, a subset of patients with euthyroid Graves disease is described.

In elderly individuals, fewer symptoms are apparent to the patient. Clues may include unexplained weight loss, hyperhidrosis, or rapid heart beat.

Young adults of Southeast Asian descent may complain of sudden paralysis thought to be related to thyrotoxic periodic paralysis. There is an association of polymorphisms of the calcium channel alpha1-subunit gene with thyrotoxic periodic paralysis. [38] One third of patients with thyrotoxic hypokalemic periodic paralysis were found to have mutations in the inwardly rectifying potassium channel (Kir2.6). [39]

The signs and symptoms of Graves disease, organized by systems, are as follows:

  • General - Fatigue, general weakness

  • Dermatologic - Warm, moist, fine skin; sweating; fine hair; onycholysis; vitiligo; alopecia; pretibial myxedema

  • Neuromuscular - Tremors, proximal muscle weakness, easy fatigability, periodic paralysis in persons of susceptible ethnic groups

  • Skeletal - Back pain, increased risk for fractures

  • Cardiovascular - Palpitations, dyspnea on exertion, chest pain, edema

  • Respiratory - Dyspnea

  • Gastrointestinal - Increased bowel motility with increased frequency of bowel movements

  • Ophthalmologic - Tearing, gritty sensation in the eye, photophobia, eye pain, protruding eye, diplopia, visual loss

  • Renal - Polyuria, polydipsia

  • Hematologic - Easy bruising

  • Metabolic - Heat intolerance, weight loss despite increase or similar appetite, worsening diabetes control

  • Endocrine/reproductive - Irregular menstrual periods, decreased menstrual volume, secondary amenorrhea, gynecomastia, impotence

  • Psychiatric - Restlessness, anxiety, irritability, insomnia



Most of the physical findings are related to thyrotoxicosis.

Physical findings that are unique to Graves disease but not associated with other causes of hyperthyroidism include ophthalmopathy and dermopathy. Myxedematous changes of the skin (usually in the pretibial areas) are described as resembling an orange peel in color and texture. Onycholysis can be seen usually in the fourth and fifth fingernails.

The presence of a diffusely enlarged thyroid gland, thyrotoxic signs and symptoms, together with evidence of ophthalmopathy or dermopathy, can establish the diagnosis.

Common physical findings, organized by anatomic region, are as follows:

  • General - Increased basal metabolic rate, weight loss despite increased or similar appetite (in pediatrics, poor weight gain with a hyperdynamic state)

  • Skin - Warm, most, fine skin; increased sweating; fine hair; vitiligo; alopecia; pretibial myxedema

  • Head, eyes, ears, nose, and throat - Chemosis, conjunctival irritation, widening of the palpebral fissures, lid lag, lid retraction, proptosis, impairment of extraocular motion, visual loss in severe optic nerve involvement, periorbital edema

  • Neck - Upon careful examination, the thyroid gland generally is diffusely enlarged and smooth; a well-delineated pyramidal lobe may be appreciated upon careful palpation; thyroid bruits and, rarely, thrills may be appreciated; thyroid nodules may be palpable.

  • Chest - Gynecomastia; tachypnea; tachycardia; murmur; hyperdynamic precordium; S3, S4 heart sounds; ectopic beats; irregular heart rate and rhythm

  • Abdomen - Hyperactive bowel sound

  • Extremities - Edema, acropachy, onycholysis

  • Neurologic - Hand tremor (fine and usually bilateral), hyperactive deep tendon reflexes

  • Musculoskeletal - Kyphosis, lordosis, loss of height (in pediatrics, craniosynostosis and increased height for age), proximal muscle weakness, hypokalemic periodic paralysis in persons of susceptible ethnic groups

  • Psychiatric - Restlessness, anxiety, irritability, insomnia, depression

Ophthalmopathy is a hallmark of Graves disease. Approximately 25-30% of patients with Graves disease have clinical evidence of Graves ophthalmopathy. Progression from mild to moderate/severe ophthalmopathy occurs in about 3% of cases. [40] TSH receptor is highly expressed in the fat and connective tissue of patients with Graves ophthalmopathy. Measuring diplopia fields, eyelid fissures, range of extraocular muscles, visual acuity, and proptosis provides quantitative assessment to follow the course of ophthalmopathy. Signs of corneal or conjunctival irritation include conjunctival injection and chemosis. A complete ophthalmologic examination, including retinal examination and slit-lamp examination by an ophthalmologist, is indicated if the patient is symptomatic.

Although thyroid nodule(s) may be present, excluding multinodular toxic goiter (especially in older patients) as the cause of thyrotoxicosis is essential. The approach to treatment may be different. Excluding thyroid neoplasia is also important in these patients because reports have indicated that differentiated thyroid cancer is probably more common in patients with Graves disease and may also have a more aggressive course in these patients. [41]

Similarly, mortality has been reported to be increased in patients with Graves disease and differentiated thyroid carcinoma compared with euthyroid control patients with differentiated thyroid carcinoma. [42] Graves disease patients had also higher mortality rates compared with general population, with a particular increase in mortality due to cardiovascular and lung disorders, while hyperthyroid patients had increased mortality secondary to toxic nodules had increased mortality associated with malignancies. [43]



Graves disease is autoimmune in etiology, and the immune mechanisms involved may be one of the following:

  • Expression of a viral antigen (self-antigen) or a previously hidden antigen

  • The specificity crossover between different cell antigens with an infectious agent or a superantigen

  • Alteration of the T cell repertoire, idiotypic antibodies becoming pathogenic antibodies

  • New expression of HLA class II antigens on thyroid epithelial cells (eg, HLA-DR antigen)

The autoimmune process in Graves disease is influenced by a combination of environmental and genetic factors.

Several autoimmune thyroid disease susceptibility genes have been identified: CD40, CTLA-4, TG, TSHR, and PTPN22. [10] Some of these susceptibility genes are specific to either Graves disease or Hashimoto thyroiditis, while others confer susceptibility to both conditions. HLA-DRB1 and HLA-DQB1 also appear to be associated with Graves disease susceptibility. Genetic factors contribute approximately 20-30% of overall disease susceptibility.

  • Cytotoxic T lymphocyte-associated molecule-4 (CTLA-4) is a major thyroid autoantibody susceptibility gene, [44, 45] and it is a negative regulator of T-cell activation and may play an important role in the pathogenesis of Graves disease. The G allele of exon1 +49 A/G single nucleotide polymorphism (SNP) of the CTLA-4 gene influences higher TPOAb and TgAb production in patients who are newly diagnosed with Graves disease. [44] This SNP of the CTLA-4 gene can also predict recurrence of Graves disease after cessation of thionamide treatment. [46]

  • There is an association of a C/T SNP in the Kozak sequence of CD40 with Graves disease. [10, 47]

  • The association of SNPs in PTPN22 varies among autoimmune diseases individually or as part of a haplotype, and the mechanisms by which PTPN22 confers susceptibility to Graves disease may differ from other autoimmune diseases. [48]

  • Alleles of intron 7 of the TSH-receptor gene (TSHR) have also been shown to contribute to susceptibility to Graves disease.

  • Inhibitory antibodies directed against insulinlike growth factor receptor-1 (IGFR-1) were seen in 14% of patients with Graves ophthalmopathy, but there was no activation of IGFR-1 in association with these antibodies. [49]

Environmental factors associated with susceptibility are largely unproven. Other factors include infection, iodide intake, stress, female sex, steroids, and toxins. Smoking has been implicated in the worsening of Graves ophthalmopathy.

  • Graves disease has been associated with a variety of infectious agents such as Yersinia enterocolitica and Borrelia burgdorferi. Homologies have been shown between proteins of these organisms and thyroid autoantigens. [50, 51]  Graves disease has also been linked to viral infections, including with SARS-CoV-2 (the pathogen for coronavirus disease 2019 [COVID-19]). [6, 7, 8]

  • Stress can be a factor for thyroid autoimmunity. Acute stress-induced immunosuppression may be followed by immune system hyperactivity, which could precipitate autoimmune thyroid disease. This may occur during the postpartum period, in which Graves disease may occur 3-9 months after delivery. Estrogen may influence the immune system, particularly the B-cell repertoire. Both T- and B-cell function are diminished during pregnancy, and the rebound from this immunosuppression is thought to contribute to the development of postpartum thyroid syndrome.

  • Immune checkpoint inhibitors (eg, anti–CTLA-4 antibody [ipilimumab], anti–PD-1 antibodies [nivolumab, pembrolizumab, cemiplimab], anti–PD-L1 antibodies [avelumab, atezolizumab, durvalumab]), interferon beta-1b, and IL-4, when used therapeutically, may cause Graves disease.

  • Trauma to the thyroid has also been reported to be associated with Graves disease. This may include surgery of the thyroid gland, percutaneous injection of ethanol, and infarction of a thyroid adenoma.