Basedow's disease: causes, symptoms, diagnosis and treatment

By Cristiano Antonino On Jun 2, 2023

Basedow’s disease or disease is an autoimmune disease that affects the thyroid gland, and is most common among women, with a male/female ratio of 1:5-10

It can occur at any age, but is more frequent over the age of sixty and in the third / fourth decade of life.

The immune system of a person suffering from this pathology recognizes the thyroid as foreign to the body and attacks it, producing antibodies against the TSH receptor (TSH-receptor antibodies, TRAb) located on the thyroid cells.

These receptors are stimulated by antibodies and lead to excessive production of thyroid hormones, T3 and T4.

Symptoms of Basedow’s disease

Especially when the disease begins to appear in the patient, it can be difficult to identify it because the symptoms of Basedow’s disease can be little accentuated or confused with those of other pathologies. The first to appear are in fact disorders of a psychic nature.

The patient can thus suffer from states of anxiety, difficulty falling asleep, excessive emotionality, irritability, a feeling of general restlessness, easy worry for irrelevant or non-existent reasons, depression, tremors and easy mental fatigue.

However, we know that hyperthyroidism causes an increase in basal metabolic rate, the consequences of which are:

the acceleration of the heartbeat (tachycardia and arrhythmia up to atrial fibrillation);
heat intolerance with a lot of sweating;
hand tremor with rapid swings;
the increased sense of hunger with an increase in the bowel habit and a tendency to lose weight;
difficulty concentrating;
insomnia;
enlarged thyroid gland (goiter) with swelling in the front of the neck.

Between 25 and 80% of people with Basedow disease develop Basedowian ophthalmopathy, characterized by exophthalmos with eye inflammation, a condition in which the eyes roll out, become bulging and fixed.

If at least at the beginning the eye symptoms are limited to increased tearing, with photophobia, corneal and/or conjunctival irritation and a feeling of sand in the eyes, unfortunately it often happens that the eye disease becomes more serious leading to the need for surgical treatment .

To date, it is still not entirely clear to doctors and researchers the real reason and cause of the involvement of the eye in this disease.

Causes

Basedow-Graves disease is a form of autoimmune thyroiditis and is influenced by an important genetic and hereditary component.

For this reason it is important to investigate the familiarity of the subject and the possibility that he/she and/or his family have other autoimmune pathologies both of the thyroid and of other organs or systemic pathologies (type I diabetes, celiac disease, rheumatoid arthritis, lupus, vitiligo).

In fact, patients can find abnormal antibodies directed against the TSH receptor (which stimulates the synthesis of thyroid hormones).

The binding of these antibodies to the TSH receptor mimics the stimulatory effects of the hormone on glandular activity.

The consequence is a thyrotoxicosis due to functional hyperactivation of the thyroid, with an increase in circulation of both thyroid hormones (FT4 and FT3) and suppression of TSH.

There are sometimes several cases in the family of autoimmune thyroiditis or autoimmune diseases in which a responsible gene or group of genes has been identified for some types.

Further causes that are hypothesized could trigger this form of hyperthyroidism are previous viral infections in which the immune system confuses viral antigens with autologous thyroid antigens.

Basedow-Graves disease is usually favored if the subject is in a period of strong mental or organismal stress, precisely because the immune system in case of suffering can give rise to malfunctions in predisposed subjects.

Diagnosis

Depending on age, early diagnosis may be particularly important.

In elderly people, for example, it can lead to atrial fibrillation due to an unacknowledged and neglected hyperthyroidism over time.

In order to diagnose Basedow’s disease, in addition to the clinical examination of the patient by the specialist doctor, it is essential to define the dosage of thyroid hormones, TSH and antithyroid antibodies, associated with ultrasound images of the thyroid with color Doppler ultrasound.

Through Doppler it is possible to evaluate the peak systolic velocity of the inferior thyroid artery, giving diagnostic confirmation of glandular hyperfunction.

Once hyperthyroidism is suspected following the clinic visit, the blood dosage of TSH, FT3 and FT4 photographs with the utmost accuracy the thyroid hyperfunction and therefore the level of severity of the same.

The ultrasound of the thyroid shows a gland with evidently inhomogeneous echostructure and reduced diffuse echogenicity of the parenchyma, pseudonodules, characteristic intraglandular hypervascularization.

Risks of Basedow’s disease

The remission rate of hyperthyroidism is around 30-50%.

Factors that make such a remission less likely are:

male
old age
smoking habit
severity at the onset of hyperthyroidism especially if T3-toxicosis is present
very high and persistent values despite TRAb therapy
enlarged thyroid
occurrence of orbitopathy

It is therefore important to understand that hyperthyroidism must be resolved with therapy, because in the long term it leads to damage to various organs, first of all the heart (up to heart failure and atrial fibrillation) and bones (osteoporosis with increased risk of fractures ).

Basedow’s disease interventions and therapies

The goal of a good therapy for Basedow’s disease is to reduce the amount of circulating thyroid hormones and for this reason we resort to thyrostatic drugs, thionamides.

These medicines include methimazole, the most widely used as it has proven to be more effective and well tolerated.

They have a dual mechanism:

inhibit thyroid peroxidases (the incorporation of iodine and the consequent synthesis of thyroid hormones)
they have an immunomodulatory action (they attenuate the phenomena of hyperreactivity of the immune system on the thyroid)

Pharmacological therapy, however, must proceed in gradually decreasing doses and must be continued as the thyroid hormones return to the normal range, therefore until the hyperthyroidism syndrome has remitted (therefore it can indicatively last from 6 to 24 months).

If taking medicines does not produce the desired results or has to be stopped due to too many side effects, the doctor may decide to surgically remove a large part of the thyroid gland (total thyroidectomy) or treat it with radioactive iodine (radiometabolic iodine therapy131).

Total thyroidectomy surgery removes the root of the problem, effectively eliminating the thyroid (hypothyroidism) which, however, must be replaced by thyroxine therapy.

Thyroidectomy is indicated in case of:

large goiters unsuitable for radioiodine therapy
presence of thyroid nodules with diagnosis or only suspicion of malignancy
need for resolution of hyperthyroidism in a short time
severe and active Basedowian orbitopathy

In radioiodine therapy, on the other hand, the patient ingests a capsule containing radioactive iodine, which is selectively picked up by the thyroid and destroys the cells that work too much.

It is a less expensive treatment and increasingly adopted by patients who have persistent hyperthyroidism that does not resolve with medical therapy and who have contraindications for surgery.

Complications from therapies

Total thyroidectomy surgery requires a 5% Lugol’s solution therapy in the 7-10 days preceding it to reduce the vascularisation of the thyroid and facilitate its removal.

In the absence of this preparation, in fact, the risk of post-operative haemorrhage increases.

The two main complications of the surgery are:

transient or permanent hypocalcaemia
dysphonia due to recurrent nerve lesions

These complications are significantly reduced if the operation is performed by surgeons with adequate thyroid training and who work in specialized centers that perform at least 100 thyroidectomies a year.

Radioiodine therapy, on the other hand, is discarded in the case of moderate-to-severe Basedowian orbitopathy because it can lead to worsening.

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