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==Causes==
==Causes==
Graves' disease may be caused by either genetic factors, autoimmune antibodies against thyrotropin receptors, T cells and B cells auto activation and infectious agents.
Graves' disease may be caused by either genetic factors, autoimmune antibodies against thyrotropin receptors, T cells and B cells auto activation and infectious agents.
Graves' disease is an [[autoimmunity|autoimmune]] disorder, in which the body produces [[antibody|antibodies]] to the receptor for thyroid-stimulating hormone (TSH). (Antibodies to thyroglobulin and to the [[thyroid hormone]]s T3 and T4 may also be produced.)
These antibodies cause [[hyperthyroidism]] because they bind to the TSH receptor and [[chronic (medicine)|chronically]] stimulate it. The TSH receptor is expressed on the [[follicular cells]] of the thyroid gland (the cells that produce thyroid hormone), and the result of chronic stimulation is an abnormally high production of T3 and T4. This in turn causes the clinical symptoms of [[hyperthyroidism]], and the enlargement of the thyroid gland visible as [[Goitre|goiter]].


The infiltrative [[exophthalmos]] that is frequently encountered has been explained by postulating that the thyroid gland and the extraocular muscles share a common antigen which is recognized by the antibodies. Antibodies binding to the extraocular muscles would cause swelling behind the eyeball.
===Causes by Organ System===


The "orange peel" skin has been explained by the infiltration of antibodies under the skin, causing an inflammatory reaction and subsequent fibrous plaques.
{|style="width:80%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" |'''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | No underlying causes
|-
|bgcolor="LightSteelBlue"| '''Chemical/Poisoning'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| CD 25 gene mutations, CD 40 gene mutations, Cytotoxic t-lymphocyte–associated antigen 4 gene mutations, HLA-DRβ-arg74 gene mutations, The protein tyrosine phosphatase nonreceptor type 22 (ptpn22) gene mutations, Thyroglobulin gene mutations, Thyrotropin receptor gene mutations.
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| [[Yersinia enterocolitica]]
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal/Orthopedic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional/Metabolic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Ophthalmologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Overdose/Toxicity'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Renal/Electrolyte'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Rheumatology/Immunology/Allergy'''
|bgcolor="Beige"| Anti thyrotropin receptor antibodies
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| No underlying causes
|-
|}


There are 3 types of autoantibodies to the TSH receptor currently recognized:
===Causes in Alphabetical Order===
 
{{Columns-list|3|
* ''TSI'', Thyroid stimulating immunoglobulins: these antibodies (mainly IgG) act as LATS (Long Acting Thyroid Stimulants), activating the cells in a longer and slower way than TSH, leading to an elevated production of thyroid hormone.
 
* ''TGI'', Thyroid growth immunoglobulins: these antibodies bind directly to the TSH receptor and have been implicated in the growth of thyroid follicles.
 
* ''TBII'', Thyrotrophin Binding-Inhibiting Inmunoglobulins: these antibodies inhibit the normal union of TSH with its receptor. Some will actually act as if TSH itself is binding to its receptor, thus inducing thyroid function. Other types may not stimulate the thyroid gland, but will prevent TSI and TSH from binding to and stimulating the receptor.
 
The trigger for auto-antibody production is not known. There appears to be a [[genetics|genetic]] predisposition for Graves' disease, suggesting that some people are more prone than others to develop TSH receptor activating antibodies due to a genetic cause. [[Human leukocyte antigen|HLA]] DR (especially DR3) appears to play a significant role.<!--
  --><ref name="EndocrReview1993">{{cite journal | author = Tomer Y, Davies T | title = Infection, thyroid disease, and autoimmunity. | journal = Endocr Rev | volume = 14 | issue = 1 | pages = 107-20 | year = 1993 | id = PMID 8491150 | url=http://edrv.endojournals.org/cgi/reprint/14/1/107.pdf | format=PDF}}</ref>
 
Since Graves' disease is an autoimmune disease which appears suddenly, often quite late in life, it is thought that a [[Virus|viral]] or [[Bacteria|bacterial]] infection may trigger antibodies which cross-react with the human TSH receptor (a phenomenon known as antigenic mimicry, also seen in some cases of type I [[diabetes]]).
 
One possible culprit is the bacterium ''[[Yersinia enterocolitica]]'' (a cousin of ''[[Yersinia pestis]]'', the agent of bubonic plague). However, although there is indirect evidence for the structural similarity between the bacteria and the human thyrotropin receptor, direct causative evidence is limited.<!--
  --><ref name="EndocrReview1993"/>
''Yersinia'' seems not to be a major cause of this disease, although it may contribute to the development of thyroid autoimmunity arising for other reasons in genetically susceptible individuals.<!--
  --><ref>{{cite journal | author = Toivanen P, Toivanen A | title = Does Yersinia induce autoimmunity? | journal = Int Arch Allergy Immunol | volume = 104 | issue = 2 | pages = 107-11 | year = 1994 | id = PMID 8199453}}</ref>
It has also been suggested that ''Y. enterocolitica'' infection is not the cause of auto-immune thyroid disease, but rather is only an associated condition; with both having a shared inherited susceptibility.<!-- yes this is true
  --><ref>{{cite journal | author = Strieder T, Wenzel B, Prummel M, Tijssen J, Wiersinga W | title = Increased prevalence of antibodies to enteropathogenic ''Yersinia enterocolitica'' virulence proteins in relatives of patients with autoimmune thyroid disease. | journal = Clin Exp Immunol | volume = 132 | issue = 2 | pages = 278-82 | year = 2003 | id = PMID 12699417}}</ref>
More recently the role for ''Y. enterocolitica'' has been disputed.<!--
  --><ref>{{cite journal | author = Hansen P, Wenzel B, Brix T, Hegedüs L | title = Yersinia enterocolitica infection does not confer an increased risk of thyroid antibodies: evidence from a Danish twin study. | journal = Clin Exp Immunol | volume = 146 | issue = 1 | pages = 32-8 | year = 2006 | id = PMID 16968395}}</ref>
 
The ocular manifestations of Graves disease are more common in smokers and tend to worsen (or develop for the first time) following radioiodine treatment of the thyroid condition. Thus, they are '''not''' caused by hyperthyroidism ''per se''; this common misperception may result from the fact that hyperthyroidism from other causes may cause eyelid retraction or eyelid lag (so-called ''hyperthyroid stare'') which can be confused with the general appearance of proptosis/exophthalmos, despite the fact that the globes do not actually protrude in other causes of hyperthyroidism. Also, both conditions (globe protrusion and hyperthyroid lid retraction) may exist at the same time in the hyperthyroid patient with Graves disease.


==References==
==References==

Revision as of 16:04, 13 December 2016

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

Causes

Graves' disease may be caused by either genetic factors, autoimmune antibodies against thyrotropin receptors, T cells and B cells auto activation and infectious agents.

Causes by Organ System

Cardiovascular No underlying causes
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect No underlying causes
Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic CD 25 gene mutations, CD 40 gene mutations, Cytotoxic t-lymphocyte–associated antigen 4 gene mutations, HLA-DRβ-arg74 gene mutations, The protein tyrosine phosphatase nonreceptor type 22 (ptpn22) gene mutations, Thyroglobulin gene mutations, Thyrotropin receptor gene mutations.
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease Yersinia enterocolitica
Musculoskeletal/Orthopedic No underlying causes
Neurologic No underlying causes
Nutritional/Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Ophthalmologic No underlying causes
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal/Electrolyte No underlying causes
Rheumatology/Immunology/Allergy Anti thyrotropin receptor antibodies
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Miscellaneous No underlying causes

Causes in Alphabetical Order

{{Columns-list|3|

References

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