Primary Symptoms of Graves' Disease
Graves' disease presents with a constellation of hypermetabolic symptoms including weight loss, palpitations, heat intolerance, tremors, anxiety, and diarrhea, along with distinctive physical findings of diffuse goiter and, in some patients, characteristic ophthalmopathy (eyelid lag or retraction) and pretibial myxedema. 1
Core Hypermetabolic Symptoms
The primary clinical manifestations reflect excessive thyroid hormone production and include:
- Weight loss despite normal or increased appetite 1
- Palpitations and tachycardia from increased cardiac stimulation 1, 2
- Heat intolerance and excessive sweating due to elevated metabolic rate 1
- Tremors (fine motor tremor of the hands) 1
- Anxiety, nervousness, and emotional lability 1, 2
- Diarrhea from increased gastrointestinal motility 1
- Insomnia and sleep disturbances 1, 3
- Fatigue and muscle weakness despite hyperactivity 1, 2
- Hyperkinesis (increased motor activity) 2
Distinctive Physical Findings
Graves' disease has unique features that distinguish it from other causes of hyperthyroidism:
Thyroid Gland
- Diffuse goiter (smooth, symmetrical thyroid enlargement) 1, 4
- Thyroid bruit may be audible on auscultation 1
Ophthalmopathy (25% of patients)
- Eyelid lag or retraction (distinctive sign) 1
- Exophthalmos (eye protrusion) 4
- The ophthalmopathy can be non-infiltrative or infiltrative 4
Dermatologic Manifestations
Cardiovascular Manifestations
- Tachycardia (resting heart rate often >90 bpm) 1
- Hypertension (particularly systolic) 1
- In rare severe cases, flash pulmonary edema can occur 3
Atypical Presentations
Important caveat: Not all patients present classically. "Apathetic thyrotoxicosis" can occur, particularly in elderly patients, where hypermetabolic symptoms may be masked or minimal, potentially delaying diagnosis 4. Some patients may present with predominantly cardiovascular symptoms or psychiatric manifestations 3.
Diagnostic Confirmation
When these symptoms are present, diagnosis is confirmed by:
- Elevated free T4 or total T3 with suppressed TSH (typically <0.1 mU/L) 1, 4
- Positive thyroid-stimulating immunoglobulin (TSI) or TSH receptor antibodies (TRAb) to distinguish from other causes of thyrotoxicosis 1
Critical Distinction
Physical examination findings of ophthalmopathy or thyroid bruit are diagnostic of Graves' disease and should prompt early endocrine referral, as these features distinguish it from other causes of hyperthyroidism like thyroiditis 1.