Graves’ Disease: Complications

Thyroid storm is an acute and life-threatening worsening of hyperthyroidism, characterized by an exacerbation of symptoms and signs of hyperthyroidism, with high fever, dehydration, marked tachycardia or tachyarrhytmias, heart failure, hepatomegaly, respiratory distress, abdominal pain, delirium, possibly seizures. It may occur in patients submitted to thyroidectomy or radioactive iodine treatment while hyperthyroid, or as a consequence of infections in unteated hyperthyroid patients. Treatment consists of antithyroid drug treatmnt, rest, sedation, fluid and electrolyte replacement, cardio-supportive therapy, oxygen therapy, antibiotics, cooling. Mortality is about 10%. Graves’ orbitopathy (GO) is the main extrathyroidal manifestation of Graves’ disease, found in about 25% of patients at diagnosis, often mild and self-remitting. Removal of risk factors (refrain from smoking, correction of thyroid dysfunction, oral steroid prophylaxis after radioactive iodine therapy, antioxidant therapy with seleniomethionine) are fundamental to prevent progression of mild GO to more severe forms. In moderate-to-severe and active GO, intravenous glucocorticoids are the first-line treatment, second line treatments include cyclosporine, orbital radiotherapy, rituximab (controversial). Novel biologicals, such as teprotumumab and tocilizumab are under investigation. Rehabilitative surgery (orbital decompression, squint surgery, eyelid surgery) is often required. Thyroid dermopathy (pretibial myxedema) is a rare complication of Graves’ disease, usually observed in patients who also have severe GO. Topical glucocorticoids are usually effective. Thyroid acropachy (clubbing of fingers and toes, with swelling of hands and feet) is an extremely rare conditions, for which no treatment is available. Hypertyroidism may be complicated by severe cardiovascular manifestations, such as tachyarrhythmias (most commonly atrial fibrillation), congestive heart failure, angina, particularly in the elderly or in patients with preexisting heart abnormalities. Prompt restoration of euthyroidism is, therefore, warranted, as well as specific treatments for the heart.